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HPI elements - use the past medical history

  1. #1
    Default HPI elements - use the past medical history
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    Can you use the past medical history for the ROS. I am utilizing the family history and social history for the PFSH elements. I am just missing the ROS. Note reads:

    Past Medical History: 1. Asthma. 2. Depression. 3. ? of Marfan's syndrome

    Can I count Resp and Psych = 2 ROS.

    Please help?????
    Thanks,
    Kristen
    Kristen Richard, CPC

  2. #2
    Default
    If that is all you have I would say no.

    Sometimes they will list things out like 1.Asthma-carries inhaler but hasn't used for several months. 2. Depression- no suicidal thoughts, currently being managed by a psychiatrist. etc.. In those cases you could pull ROS but the way it is listed they didn't document anything that leads me to believe they asked about current status of the involved systems.


    Laura, CPC, CPMA, CEMC

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default I would count it
    Laura and I usually agree (and are on the conservative - "stickler" - side most of the time).

    But ROS can be taken by anyone; does not have to be done by the provider. And frequently patients fill out a "questionaire" that just asks them to check mark yes or no next to a list of conditions.

    So, if there is no other ROS documented and the rest of the note really meets the requirements in terms of medical necessity, MDM, exam, etc, then I'd be inclined to count this as ROS.

    BUT ... I would also use this as an example for educating the physician on "audit-proof" documentation (i.e. this one makes us stretch for the bullet point).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. Default
    Sorry but I would have to say no way does that even come close to counting for any ROS. PMH 1. asthma 2. depression.......... No way. If they expanded on that at all as far as current symptoms or anything then sure, but definately not the way it is there.

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