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Using HPI for ROS

  1. Post Using HPI for ROS
    Medical Coding Books
    If the doctor documents the following:

    History:
    Jane Doe is a 52 year old female
    Patient presents with:
    DRY EYE - pt requesting ref to opthamology

    Had lasik 2 yrs, now complains of 1 year of dry eyes and 2 weeks of eye redness. Uses over the counter drops for dry eyes already.

    - can you use eye redness for ROS
    Is there any clear documentation on what is applicable to be used from the HPI for the ROS

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default It depends on how much HPI you need
    Depending on what level of E/M your looking at ... you may only need 1 element of the HPI ...so, yes, I'd use anything else not needed for the HPI towards ROS. )I'm assuming that there is no clearly identifiable ROS listed elsewhere.)

    F Tessa Bartels,CPC, CPC-E/M
    Last edited by FTessaBartels; 11-18-2008 at 04:54 PM.

  3. #3
    Location
    North Carolina
    Posts
    3,126
    Default
    Yep...I would, too.

  4. #4
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    well - before I would have said "no" - but I've since learned, that yes you can (see, you can teach an old dog new tricks) I agree with Tessa and Rebecca - yup, I too would use it in the ROS if needed and 'not' already used in the HPI ..
    Donna, CPC, CPC-H

  5. #5
    Location
    North Carolina
    Posts
    3,126
    Default
    Donna,

    Just when I think I know something...someone shuffles the deck. You guys are great!!

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