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Wiki ROS unclear

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anthia

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Cocolalla, ID
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My provider saw a new patient and did an excellent job on the HPI, with complete history, documentation of symptoms, time, etc. However on the ROS she only states "ROS as noted in the HPI" Is that enough for me to pull some info from the HPI, without double-dipping, to cover an ROS. I hate to bill it as a 99201 as there was quite a bit going on with this patient.
 
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Yes. There is no requirement for the ROS to be listed separately. I have seen many providers use a statement such as this and some even expand on it by stating, "14 point system review negative except as noted in the HPI."
 
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If there is documentation of relevant systems in the HPI other than the one relating to the chief complaint, ("Pt has headache, denies blurred vision, ear pain, nausea, vomiting" etc.) I would count it. It's in the subjective portion of the record, which is ultimately what matters.
 
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