Wiki Hpi,ros,exam templates

opiecpc

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Our physicians use a template where they circle the elements of a HPI,ROS,and EXAM. More often than not they'll circle everything even though those systems/body areas aren't pertinent to the CC. In this situation would it be correct to count those systems/body areas to arrive at an appropriate E/M level of service? Thank You in advance. In circling,checking off the elements,body systems,etc, is this considered documenting? Thanks
 
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Just circling or ...

For HPI: are they just circling Location / Duration / etc?

For ROS: Are they just circling the system or are they checking Yes or No / Postive or Negative?

Are they not writing ANYTHING down?

No - No - No ... I would not give credit if it is as I've described.

Would be helpful if we could actually see what this document looks like.

F Tessa Bartels, CPC, CEMC
 
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