I am struggling to get a clear (black and white) answer regarding the Review of Systems and the History of Present Illness.
All of the training I have received with regards to auditing records has told me that the ROS needs to be separate from the the HPI. So, if patient presents with a sore throat than that is part of the HPI and ENT can't be counted in the ROS unless Ears or Nose are reviewed. That might not be the best example, but I think you get the gist of it.
Now I am being questioned regarding this information by one of my clinicians and so I have been digging for proof that I am not making this logic up. The problem is that I am finding conflicting information and I am hoping someone can clarify or direct me to the "correct" answer.
CMS Documentation Guidelines state "a problem pertinent ROS inquires about the system directly related to the problem identified in the HPI", this leads me to believe that the ROS can be the system that is part of the HPI. Of course they expand this for each level, but they all state "related to the problem identified in the HPI."
APPC: How to Effectively Teach Evaluation and Managment - Coding in under 1 hour states "There is a fine line between the signs and symptoms that patient shares in the HPI and those obtained via the ROS. The ROS is a distinct review of systems. For example: if the documenation reads 'patient states that her hip has been painful' credit is not given in both the HPI 'location' and to the (MS) review of systems." It goes on to explain that if the patient's complaint is followed by "no other MS issues" than it can be counted in the ROS as well as the HPI.
AMA - Medical Record Auditor 3rd Edition by Deborah Grider states as a documentation tip in reference to ROS, "Caution: do not count elements previously counted and used in the HPI. If an element was used in the HPI, it cannot be used again in the ROS".
In another area of the book it states as an auditing tip"Remember that the ROS is a series of positive and negative responses based on questions asked related to the HPI."
So, does CMS trump AAPC and AMA or the other way around? I am very confused and trying to prepare the the CPMA exam and feel like I have been doing it correctly all this time but also questioning myself now.
Please HELP!!
All of the training I have received with regards to auditing records has told me that the ROS needs to be separate from the the HPI. So, if patient presents with a sore throat than that is part of the HPI and ENT can't be counted in the ROS unless Ears or Nose are reviewed. That might not be the best example, but I think you get the gist of it.
Now I am being questioned regarding this information by one of my clinicians and so I have been digging for proof that I am not making this logic up. The problem is that I am finding conflicting information and I am hoping someone can clarify or direct me to the "correct" answer.
CMS Documentation Guidelines state "a problem pertinent ROS inquires about the system directly related to the problem identified in the HPI", this leads me to believe that the ROS can be the system that is part of the HPI. Of course they expand this for each level, but they all state "related to the problem identified in the HPI."
APPC: How to Effectively Teach Evaluation and Managment - Coding in under 1 hour states "There is a fine line between the signs and symptoms that patient shares in the HPI and those obtained via the ROS. The ROS is a distinct review of systems. For example: if the documenation reads 'patient states that her hip has been painful' credit is not given in both the HPI 'location' and to the (MS) review of systems." It goes on to explain that if the patient's complaint is followed by "no other MS issues" than it can be counted in the ROS as well as the HPI.
AMA - Medical Record Auditor 3rd Edition by Deborah Grider states as a documentation tip in reference to ROS, "Caution: do not count elements previously counted and used in the HPI. If an element was used in the HPI, it cannot be used again in the ROS".
In another area of the book it states as an auditing tip"Remember that the ROS is a series of positive and negative responses based on questions asked related to the HPI."
So, does CMS trump AAPC and AMA or the other way around? I am very confused and trying to prepare the the CPMA exam and feel like I have been doing it correctly all this time but also questioning myself now.
Please HELP!!