Hpi and ros documentation help

Messages
8
Location
Barboursville, WV
Best answers
0
For a return patient presenting with sinus and asthma symptoms, I document that in the HPI. For the Review of Systems, I only address two systems – Ears, Nose, Throat (ENT) and Respiratory – both of which I document only as the following: “as per HPI”. I don’t address any other systems.

In order to bill a level 3 or 4 visit, I need either 1 (for level 3) or 2-9 (for level 4) Review of Systems documented, right? So for this patient, would I be able to bill a level 3? Or is the Review of Systems negated by just checking “as per HPI” for each of the two systems I address?

I’m trying to figure out if it’s okay to just check “as per HPI” in the Review of Systems section and not check off any actual symptoms. I hope so b/c it’s always seemed so redundant to say things like “cough” in the HPI and then redocument it in the Respiratory section of the Review of Systems.



M
 
Top