Wiki ROS unclear

anthia

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My provider had a NEW patient come in and did a great HPI-complete history and all the elements needed for the acute problem. However, on the ROS all she wrote was "ROS as noted in the HPI". Can that comment upgrade the visit from a 99201 as there was definitely more work done? Being this is a new patient, my tendency is to keep it as a 99201 but there was a lot done for the patient so technically it's worth more. Any ideas?
 
This really depends on the documentation. In general you can use any unused elements in the HPI towards any appropriate element in the ROS.

Remember that at the end of the day, the medical chart has to stand on it's on legs, and documentation must support any selected E/M level regardless of a coder's "hunch". Apart from upholding great integrity, the chart may go to audit and be scrutinized for any wrongful coding. Proper documentation and code selection would be the only thing that can save the claim from being denied, and possible further ramifications

Hope this is helpful!
 
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