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Hpi,ros,exam templates

  1. #1
    Default Hpi,ros,exam templates
    Medical Coding Books
    Our physicians use a template where they circle the elements of a HPI,ROS,and EXAM. More often than not they'll circle everything even though those systems/body areas aren't pertinent to the CC. In this situation would it be correct to count those systems/body areas to arrive at an appropriate E/M level of service? Thank You in advance. In circling,checking off the elements,body systems,etc, is this considered documenting? Thanks
    Last edited by opiecpc; 09-11-2009 at 09:46 AM.

  2. #2
    Milwaukee WI
    Default Just circling or ...
    For HPI: are they just circling Location / Duration / etc?

    For ROS: Are they just circling the system or are they checking Yes or No / Postive or Negative?

    Are they not writing ANYTHING down?

    No - No - No ... I would not give credit if it is as I've described.

    Would be helpful if we could actually see what this document looks like.

    F Tessa Bartels, CPC, CEMC

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