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Chief Complaint - I have a auditing question

  1. #1
    Default Chief Complaint - I have a auditing question
    Medical Coding Books
    I have a auditing question regarding the chief complaint.

    Now I was wondering if it is possible to use the information in the chief compaint as part of your HPI and/or ROS?

    For instance CC: patient has fever, vomiting, headache and body aches.
    Now I know you cannot double dip so if you just use, for instance, fever as your CC can you use the rest of the CC in your HPI and/or ROS?

  2. #2
    The chief complaint should be a separate statement. If you pull the chief complaint out of the HPI, you cannot use that particular verbage for any HPI elements.

  3. Default
    The chief complaint is subjective patient data. The ROS and EXAM is objective data from the provider. Good luck!

    Simone, CPC

  4. #4
    Default ROS is subjective information
    I have to disagree, the ROS is subjective data that the patient is complaining of. The elements do fall under a SOAP format:
    O= Exam
    A= MDM (# of dx)
    P= Complexity of data and Risk

    I would use that information like you said, if you need it.

    When I teach (students or physicians) I always use this example:
    Patient comes in for fever, in speaking with the patient they state that they have been coughing really bad too, so bad they can barely function, yet the patient has been in the office for all this time and explaining their situation and has not coughed once. This would fall under the resp. system for the ROS.

    Objective findings is what the physician would find upon exam. Actual findings!

    Does that make sense?
    Mandy Flagg, CPC, CEMC
    Compliance Auditor

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