The CC is F/U of HTN and DM...it's possible to use chest pain as a HPI element (HTN) and polydipisia (DM) as a HPI element. That leaves 3 more elements for your ROS.
Can negative responses be included in the history of present illness (HPI) elements?
Per WPS Medicare Part B, yes both pertinent positives and negatives may be included in the HPI. However, as a general rule, the HPI consists of subjective complaints that come voluntarily from the patient. Pertinent negative responses that are the result of questions posed to the patient by the physician usually fall under the Review of Systems.
When scoring the review of systems (ROS), can you use the systems addressed in the history of present illness (HPI) elements or is that "double dipping"?
ROS inquiries are questions concerning the system(s) directly related to the problem(s) identified in the HPI. Therefore, it is not considered "double dipping" to use the system(s) addressed in the HPI for ROS credit.
Can a physician count a single history item in both the HPI and ROS? For example, could we count "shortness of breath" as an associated sign and symptom in the HPI and respiratory system in the ROS?
A 6. A clearly documented medical record would prevent the need to "double-dip" for HPI and ROS, but WPS Medicare, in rare circumstances, could accept counting one statement in both areas if necessary.
So...if your carrier allows for this type of scoring and you're not double dipping...you can use HPI/ROS interchangeably. Below is a great article also...
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