Wiki Review of Systems in HPI

[maine4me]

Our MAC is Highmark, and they allow for systems reviewed in the HPI to be considered as part of the ROS. However, it is not clear to me if there must be a statement saying "ROS as in HPI".

Plus, the systems reviewed in the HPI, can this come from the patient's account of the presenting problem. See example below.

Assessment and Plan
Ambulatory Assessment/Plan:
Assessment/Plan:
486 Atypical pneumonia

Additional Plan Details:
at this time - will tx with zpack - call if worsening - no cxr ordered at this time -

HPI
HPI
Nursing Chief Complaint: "Can't shake a cold", cough, fever off and on, runny nose

Physician: 54 yo f here today for evaluation of cold symptoms -- pt has been sick with cough and runny nose and fever on and off.

PT has been sick for the past 10 days -

Taking mucinex D - for the drainage and is feeling a little better - but the cough is persistent - pt has no energy - she did a 5k on Saturday - but felt she had no energyVitals:
Height 62 in / 157.48 cm
Weight 122 lbs / 55.338273 kg
BSA 1.56 m2
BMI 22.3 kg/m2
Temperature 97.6 F / 36.44 C - Tympanic
Pulse 68
Blood Pressure 110/64, Left Arm
Personal Medical History
Personal medical history: Hx of: High cholesterol

Surgical History
Past Surgical History: Hx of: Cholecystectomy, Cesarean Section, Tonsillectomy, Other - breast biopsies

Social History
Social history:
Marital Status: Married
Household members: lives home with husband
Occupation: owns cleaning business

Tobacco
Smoking History: Never smoker
Tobacco status: Has never used tobacco

Alcohol
Alcohol Intake: None

EXAM
*****
*****
General: No acute distress.

HEENT: Sclera nonicteric, TM normal bilaterally, pharynx clear without exudate.

Neck: Supple, no lymphadenopathy.

Lungs: there is wheezing in the right upper and left upper lobes - otherwise normal

Heart: Regular rate and rhythm without murmurs or rubs.

Neuro: CN II-XII grossly intact without focal deficit.

Skin: warm, dry, no lesions/rashes

If I include those systems in the patient account, I see constitutional and ears, nose, mouth and throat. If not, no ROS.

Am I on the right track? All of this doctor's notes are this way.

 

[FTessaBartels]

What are you counting for HPI vs ROS

So, what are you counting for HPI vs ROS?
You can't double dip, so if you are using "cough" as a chief complaint, or as an associated sign/symptom (i.e. for HPI), then you can't use that for ROS.


Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[Pfukada]

Review of Systems

A question came up regarding review of systems...if the patient came in with a complaint of cough & upset stomach....in our physician notes there is a separate area for ROS...and in the ROS area, the dr states reference HPI in the area for respiratory & abdoment...would you give them credit for that?

I told the dr I would downcode the encounters that were documented that way...and he argued that this was allowed.

Is there any kind of documentation anywhere that would show that this is or is not ok?

We have been looking online to find references about this...and everywhere it states that what is mentioned in the history CAN also be mentioned in the ROS....but shouldn't it state in the ROS what was positive?

Thank you so much,

Pamela ***ada
Coding Dept.
Maui Medical Group