I'm a bit confused when you talk about "medically necessary" in this regard. The MD cannot determine what is pertinent to the current problem until he/she asks the questions.
If the history elements are listed and have been reviewed, asked, documented, etc. then they should count toward the billed level of service.
Pertinent positives and negatives MUST be documented when it comes to the Review of Systems.
As you state, the "overactive bladder" may not have anything to do with the current problem. However, the MD had to ask about issues the patient was having in order to determine, bleeding disorders, seizures perhaps, etc. The fact that he got "overactive bladder" doesn't negate his need for the knowledge. He is documenting everything he learned about the patient to make an appropriate decision for this patient now. But, also so that when the patient returns, he will have all the information.
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