Wiki Need Cc/HPI/Ros help please

[Cyndi113]

Please help with a "discussion" we are having in our office. If a patient is seen in a single encounter for cc: chest pain. Then the HPI states patient seen today for chest pain and intermittent shortness of breath. Is it possible to use the chest pain and shortness of breath as the ROS as well?

Thanks,

 

[Love Coding!]

Please help with a "discussion" we are having in our office. If a patient is seen in a single encounter for cc: chest pain. Then the HPI states patient seen today for chest pain and intermittent shortness of breath. Is it possible to use the chest pain and shortness of breath as the ROS as well?

Thanks,

Dependant on your Medicare Intermediary, mine is Noridian, and according to them that is considered double dipping and it cannot count in both places...

Anyone else?

 

[btadlock1]

Please help with a "discussion" we are having in our office. If a patient is seen in a single encounter for cc: chest pain. Then the HPI states patient seen today for chest pain and intermittent shortness of breath. Is it possible to use the chest pain and shortness of breath as the ROS as well?

Thanks,

Chest pain = HPI Location
I'd use the second chest pain (It's listed twice, right?), as ROS, and SOB as HPI - Associated Signs/Sx. It doesn't matter whether you use it as HPI or ROS. No matter how you count it, you don't get more than an EPF history. Count the ROS somewhere so that you can at least get that much. Hope that helps!

 

[MnTwins29]

Along with Signs/Sx...

I would also use the SOB in HPI as "intermittent" can also fall under timing.

 

[Cyndi113]

Thanks, Ladies!