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Can I take HPI elements from ROS?

  1. #1
    Red face Can I take HPI elements from ROS?
    Medical Coding Books
    I am missing the whole HPI in a chart but I have a complete ROS. Dr no longer works for our hospital so I can't send chart back to him to complete. I know I can take elements from HPI to use for ROS, but can I take elements from ROS and use them for the HPI?

  2. #2
    Location
    North Carolina
    Posts
    3,126
    Default I don't think so...
    Quote Originally Posted by Belinda Frisch View Post
    I say yes, and I do it on occasion when necessary. There are not specific rules that I've ever seen (certainly not in the 95s or 97s themselves) about where to pull from, only that it must be contained in the documentation. There have been others discussing this in the E/M forum as it related to taking status of chronic conditions from the impression versus from the history.

    You might want to reference them for additional support.
    The provider must document the HPI and in this case, there isn't any. Ancillary staff can obtain the ROS or the patient can complete a form indicating positive/negative. How do you use information that can be delegated to ancillary staff and use it for information that requires provider involvement (HPI)?

  3. #3
    Location
    HUNTINGTON, WV
    Posts
    21
    Default
    I agree with Rebecca. The HPI must be documented by the provider, therefore cannot be taken from the ROS which ancillary staff can document.
    Last edited by jwestfall; 03-25-2010 at 10:51 AM.
    JENNIFER WESTFALL, RHIT, CPC, CGSC

  4. #4
    Default Point of Clarification
    "I am missing the whole HPI in a chart but I have a complete ROS. Dr no longer works for our hospital so I can't send chart back to him to complete. I know I can take elements from HPI to use for ROS, but can I take elements from ROS and use them for the HPI?"

    ...I do not see where this says the ROS wasn't done by the MD? And yes, if the ROS was done by ancillary staff, I agree, the MD needs to do the HPI but you can take HPI from ROS and vice-versa as long as you don't count the elements more than once.

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