That is sometimes referred to as "double dipping". Depending on how it was documented, you could allow both. (Example only)
CC: possible migraines
........patient complains of severe headache with visual disturbances...... I would count the headache as HPI and visual disturbances as a ROS.
You may want to check with your carrier also.
Q 6. 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.
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