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Past Medical History as a Review of Systems?

  1. #1
    Default Past Medical History as a Review of Systems?
    Medical Coding Books
    I have one physician who frequently lists diagnosis under past medical history and wants to use this as his Review of Systems. Is this possible? I'm having a hard time pulling out much for a review of systems, certainly having a difficult time counting this as complete ROS. I have provided an example:

    1. Right foot and ankle surgery times 7.
    2. Previous left 4th toe partial amputation due to diabetic ulcer.
    3. Previous back surgery with spinal fusion.
    4. Previous gastritis by biopsy.
    5. Previous upper and lower endoscopies.
    6. Colonic polyp that was adenomatous polyp and benign.
    7. Previous hysterectomy due to an ovarian tumor.
    8. Previous cholecystectomy.
    9. Previous ventral hernia repair.
    10. Diabetes mellitus that is now insulin dependent although it is adult onset.
    11. Hyperlipidemia.
    12. Hypercholesterolemia.
    13. Hypertension.
    14. Congestive heart failure.
    15. Chronic renal failure with previous severe acute renal failure secondary to dye exposure.
    16. AVM of the GI tract.
    17. Previous depression.
    18. Previous anxiety.
    19. Diabetic peripheral neuropathy.
    20. Gastroesophageal reflux disease.
    21. Left nasal septal deviation.
    22. Cardiomegaly.
    23. Chronic anemia which may well be multifactorial.
    24. She has a stated history of pulmonary hypertension but she says she has never had a
    coronary angiogram. She was not aware of this but it is on some of her old medical records.
    25. Obstructive sleep apnea.
    26. Previous vertigo.
    27. Migraine headaches.
    28. Irritable bowel syndrome with diarrhea dominance.
    29. Herpes zoster.
    30. Diverticulosis.
    31. Proteinuria, unclear of what degree of nephrotic syndrome she may have but I suspect
    with her other processes that she has nephrotic syndrome.
    32. Aortic atherosclerosis noted on her CAT scan this admission.

  2. #2
    Milwaukee WI
    Default Yes
    The short answer is Yes

    Physicians don't always nicely divide their notes into sections that make it easier for coders / auditors. You can take ROS elements from whereever you find them in the history section.

    A frequent question is where do you count
    ALLERGIES: Sulfa (rash)
    I count it where I need it ... sometimes as ROS (allergic/immunologic), sometimes as Past medical history.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Yes I believe it does. Basically, I'm just locating what systems the "diagnosis' under PMH belong (as long as I am not counting them as PMH as well), and build my ROS from there. Correct?

  4. #4
    Though at first go, I would not agree by picking up ROS from PMH, but on second thought it may depend. If a provider is having hard time documenting history, one may pick from there, but it would be really ambiguous whether to take one or not.
    Girish Dadhich, CPC

  5. #5
    Milwaukee WI
    Default Correct
    Quote Originally Posted by AR2728 View Post
    Yes I believe it does. Basically, I'm just locating what systems the "diagnosis' under PMH belong (as long as I am not counting them as PMH as well), and build my ROS from there. Correct?
    Correct ... you cannot count one statement in this list for PMH and ROS, but you can count any of the statements for ROS if you are not already using them for PMH.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  6. #6
    Per Highmark Medicare Services:

    13.Can I use the patients past history in the review of systems (ROS) or history of present illness (HPI) elements of the E/M score sheet?

    No. The ROS and HPI elements pertain to the chief complaint and the reason for the patients visit that day, not past history information.

    Date Posted: 10/16/2009, Date Revised: 03/22/2011


  7. #7
    Trailblazer for Medicare also states that you can't use past medical/surgical history for ROS. Statements about allergies like "NKDA" are counted towards PMH. So I'm afraid you may have difficult time with a Medicare auditor if you count PMH as ROS.
    It is better if you contact your carriers and find out what policies they have.


    Sofia, MS, CPC

  8. #8
    Thank you all for your replies. This is very useful and important information to consider.

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