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Documenting HPI & ROS

  1. #1
    Post Documenting HPI & ROS
    Medical Coding Books
    I have a physician in the group I work for that thinks the HPI and ROS are not necessary for choosing the appropriate e/m level. What would be the best way to explain that these Are Components in proper e/m selection?

    Thanks for the help!
    Sherry Pennington, CPC

  2. #2
    Daytona Beach, FL
    For a new patient visit, initial visit, consults, etc. the HPI and ROS can make or break the entire level! Without this information you have no History - or no medical necessity for that matter. The HPI establishes what brought the patient in to be seen! You can show him in the CPT book the description of these levels and that they require all 3 of the 3 key components. You could also give him a copy of the CMS 1995 guidelines which explains all of the information that needs to be documented for any level.

    A link for the 95 guidelines:

    If you have a problem with that link, just go to and on the home page click on Evaluation and Management in the left column and the links should come up.

    Hope this helps! Good luck educating this physician!
    Last edited by jdibble; 10-16-2014 at 06:59 AM.
    Jodi Dibble, CPC

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