Wiki How many elements of HPI and ROS?

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Bernadette10

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"Patient is here for a prenatal visit. She is G1P0 at 19w5d. She reports nausea has significantly improved and is only having occasional episodes of heartburn. Fetal movement is normal."
I think EPF history:
4 elements of HPI - duration of 19 weeks, associated symptoms of nausea and heartburn, severity of significantly improved, timing of occasional episodes.
1 ROS of GU for the fetal movement (can't count GI because I already counted it as associated symptoms).
1 PFSH for G1, no previous pregnancies.

Is this the only way to count these? There's no way to get a detailed history out of this, is there?
The nurse also did a depression screen as part of the nurse's notes, but this can't be counted as another ROS, can it? "Depression screen PHQ-2 total = 0." The physician didn't mention this anywhere else in his note, and it's documented as part of the nurse's notes when the patient was first seen by the nurse before seeing the physician. If I could count the depression screen as a psych ROS, then I could get a detailed history, but this is not allowed unless the physician also notes it, right? Any help is appreciated, thanks.
 
Sorry, forgot to mention that for the payer in this case, visits are billed separately, so there is no global period, so that's why I need to level it.
 
Sorry again, I forgot that ROS can be reported by ancillary staff, so I think I can count the depression screen as another ROS, so this could be a detailed history, but please correct me if I'm wrong.
 
As you said in your first post, ROS can be recorded by the staff, but can only be used toward the level if the physician documents reviewing and agreeing with them.

I would not count this as a detailed history - I personally think that's stretching the rules a little too far, including that using the term of the pregnancy as duration and 'improved' as severity don't really meet those definitions. This is an 'interval history', a brief update since the last visit, and I think your original EPF is more appropriate. Of course different auditors do these things in very different ways, and medical necessity these days is more important to payers than elements or points in an HPI, so (and this may sound like heresy to some coders) I would question the value in scrutinizing a single portion of a note to this level of detail.
 
Bernadette10 said:
"Patient is here for a prenatal visit. She is G1P0 at 19w5d. She reports nausea has significantly improved and is only having occasional episodes of heartburn. Fetal movement is normal."
I think EPF history:
4 elements of HPI - duration of 19 weeks, associated symptoms of nausea and heartburn, severity of significantly improved, timing of occasional episodes.
1 ROS of GU for the fetal movement (can't count GI because I already counted it as associated symptoms).
1 PFSH for G1, no previous pregnancies.

Is this the only way to count these? There's no way to get a detailed history out of this, is there?
The nurse also did a depression screen as part of the nurse's notes, but this can't be counted as another ROS, can it? "Depression screen PHQ-2 total = 0." The physician didn't mention this anywhere else in his note, and it's documented as part of the nurse's notes when the patient was first seen by the nurse before seeing the physician. If I could count the depression screen as a psych ROS, then I could get a detailed history, but this is not allowed unless the physician also notes it, right? Any help is appreciated, thanks.
Click to expand...
According to ACOG prenatal visits to not follow the same guidelines that are needed to meet the same criteria as a standard bullet points for EM
 
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