Past Medical History-Is it acceptable

gailmc

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Amelia, OH
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I would say yes - providers can document how they choose, and as coders it is our responsibility to separate out the hx, exam, and MDM components. It makes it much easier if it was organized in the same sequence as an audit tool, but who said coding is easy :)
 

DeeCPC

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According to CMS, past history can't be used in the ROS.
Q:
Can I use the patients past history in the review of systems (ROS) or history of present illness (HPI) elements of the E/M score sheet?

No. The ROS and HPI elements pertain to the chief complaint and the reason for the patients visit that day, not past history information.
 

CardioCoder79

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Columbia, SC
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Thanks for the response! I do have another question.... Is it acceptable to just say "Lungs:Clear" on the examination or does the verbiage have to be "Lungs:Clear to Auscultation"?
 
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i agree that ROS cant be taken from past medical history.... cause ROS is suppose to be reviewed by the provider at the time of visit and can be documented in HPI but not PMH......
 
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