I agree with Laura. Unless your carrier
specifically states that you cannot extract the ROS from the HPI, then I am comfortable doing so. There are carriers that do allow this concept.
Q-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- 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
I don't necessarily like the "single history item", but you can see that it
could be acceptable in certain situations.
Also.....Dr. McCann's response (HCFA)
The Medical Director responded with:
"It is not necessary to mention an item of history twice in order to meet the guidelines for Review of Systems. Repetition of information or data is not required as long as it is appropriately referred to. Once should be enough."
- John H. Lindberg, MD
When he received the above response he then sent the same letter to HCFA with the response from his local carrier for Dr. McCann's opinion (who is supposedly the source of the double dipping rule). Dr. McCann's response was:
"We agree with Dr. Lindberg that it is not necessary to mention an item of history twice in order to meet the Documentation Guidelines requirements for the ROS. It is important that the information which is provided can be inferred accurately and appropriately by a reviewer to determine level of service and medical necessity."
- Barton C. McCann, MD
http://www.ercoder.com/discussion/topic.php?id=17
Again...I think it boils down to responsible documenation, coding and compliance within your own carrier.