Wiki HPI and ROS

[coder21]

Is it written somewhere that if you count a area in the HPI you can not also use the same thing for the ROS because of double dipping?

 

[RebeccaWoodward*]

This is carrier discretion. Some carriers will allow this under certain circumstances and some do not allow "double dipping" at all....

 

[losborn]

NAMAS says no double dipping at all.

Lin
CPC

 

[RebeccaWoodward*]

I don't disagree but there are some carriers that will allow this in some circumstances.

Q 6. Can a physician count a single history item in both the HPI and ROS? For example, could we count "shortness of breath" as an associated sign and symptom in the HPI and respiratory system in the ROS?

A 6. A clearly documented medical record would prevent the need to "double-dip" for HPI and ROS, but WPS Medicare, in rare circumstances, could accept counting one statement in both areas if necessary.


http://www.wpsic.com/medicare/part_b/education/evalmngmntqahistory.shtml

 

[coder21]

Thank you for helping. I do have one more thing. We use a EMR. They gave credit for a location that was taking out of the musculoskeletal section of the physical exams. Is this ok? Where can I found it in writing?

Thank you

 

[dwaldman]

Q 6. Can a physician count a single history item in both the HPI and ROS? For example, could we count "shortness of breath" as an associated sign and symptom in the HPI and respiratory system in the ROS?
A 6. A clearly documented medical record would prevent the need to "double-dip" for HPI and ROS, but WPS Medicare, in rare circumstances, could accept counting one statement in both areas if necessary.

http://www.wpsic.com/medicare/part_b/education/evalmngmntqahistory.shtml