# Review of Systems ROS -v- History of Present Illness HPI



## Captain74

I am struggling to get a clear (black and white) answer regarding the Review of Systems and the History of Present Illness.

All of the training I have received with regards to auditing records has told me that the ROS needs to be separate from the the HPI.  So, if patient presents with a sore throat than that is part of the HPI and ENT can't be counted in the ROS unless Ears or Nose are reviewed.  That might not be the best example, but I think you get the gist of it.

Now I am being questioned regarding this information by one of my clinicians and so I have been digging for proof that I am not making this logic up.  The problem is that I am finding conflicting information and I am hoping someone can clarify or direct me to the "correct" answer.

*CMS Documentation Guidelines *state "a problem pertinent ROS inquires about the system directly related to the problem identified in the HPI", this leads me to believe that the ROS can be the system that is part of the HPI.  Of course they expand this for each level, but they all state "related to the problem identified in the HPI."

*APPC:  How to Effectively Teach Evaluation and Managment - Coding in under 1 hour *states "There is a fine line between the signs and symptoms that patient shares in the HPI and those obtained via the ROS.  The ROS is a distinct review of systems.  For example: if the documenation reads 'patient states that her hip has been painful' credit is not given in both the HPI 'location' and to the (MS) review of systems."  It goes on to explain that if the patient's complaint is followed by "no other MS issues" than it can be counted in the ROS as well as the HPI.

*AMA - Medical Record Auditor 3rd Edition by Deborah Grider *states as a documentation tip in reference to ROS, "Caution: do not count elements previously counted and used in the HPI.  If an element was used in the HPI, it cannot be used again in the ROS".  

In another area of the book it states as an auditing tip"Remember that the ROS is a series of positive and negative responses based on questions asked related to the HPI."

So, does CMS trump AAPC and AMA or the other way around?  I am very confused and trying to prepare the the CPMA exam and feel like I have been doing it correctly all this time but also questioning myself now.

Please HELP!!


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## btadlock1

Captain74 said:


> I am struggling to get a clear (black and white) answer regarding the Review of Systems and the History of Present Illness.
> 
> All of the training I have received with regards to auditing records has told me that the ROS needs to be separate from the the HPI.  So, if patient presents with a sore throat than that is part of the HPI and ENT can't be counted in the ROS unless Ears or Nose are reviewed.  That might not be the best example, but I think you get the gist of it.
> 
> Now I am being questioned regarding this information by one of my clinicians and so I have been digging for proof that I am not making this logic up.  The problem is that I am finding conflicting information and I am hoping someone can clarify or direct me to the "correct" answer.
> 
> *CMS Documentation Guidelines *state "a problem pertinent ROS inquires about the system directly related to the problem identified in the HPI", this leads me to believe that the ROS can be the system that is part of the HPI.  Of course they expand this for each level, but they all state "related to the problem identified in the HPI."
> 
> *APPC:  How to Effectively Teach Evaluation and Managment - Coding in under 1 hour *states "There is a fine line between the signs and symptoms that patient shares in the HPI and those obtained via the ROS.  The ROS is a distinct review of systems.  For example: if the documenation reads 'patient states that her hip has been painful' credit is not given in both the HPI 'location' and to the (MS) review of systems."  It goes on to explain that if the patient's complaint is followed by "no other MS issues" than it can be counted in the ROS as well as the HPI.
> 
> *AMA - Medical Record Auditor 3rd Edition by Deborah Grider *states as a documentation tip in reference to ROS, "Caution: do not count elements previously counted and used in the HPI.  If an element was used in the HPI, it cannot be used again in the ROS".
> 
> In another area of the book it states as an auditing tip"Remember that the ROS is a series of positive and negative responses based on questions asked related to the HPI."
> 
> So, does CMS trump AAPC and AMA or the other way around?  I am very confused and trying to prepare the the CPMA exam and feel like I have been doing it correctly all this time but also questioning myself now.
> 
> Please HELP!!



When you have all of the history condensed into one paragraph, you sort of pick and choose your HPI and ROS out of it. Deborah Grider's advice is correct; if you count a phrase as HPI, you can't also count it as ROS. Picking out what's what is pretty difficult when you're first starting out. The best way for me to do it, was to break the whole note down and figure out how everything could be counted, then decide what I would count things as. Let me give you an example:
"Patient C/O diarrhea and vomiting. The problems began early this morning with multiple episodes of emesis during the night. He now feels dizzy and tired when standing. There has been no blood or mucous in the watery stool or vomit. No other family members are ill yet. He hasn't traveled outside of this area or changed his diet significantly."

Fortunately, our EMR has a separate section for ROS, so I don't have to deal with picking and choosing where to credit things, but for the sake of argument, I'll pretent this is all there is to the history. Here's how it could be broken down:
*Patient C/O diarrhea and vomiting*. - This is the CC (which can be shared with ROS and/or HPI). Since the CC can be shared, I'll count diarrhea as CC & ROS: GI, and the vomiting as HPI: Assoc. Signs/Sx
*The problems began early this morning* - HPI Duration
*with multiple episodes of emesis during the night.* HPI Contect and Timing (multi episodes = timing, during the night = context)
*He now feels dizzy and tired when standing*. This could be more HPI Assoc Signs or HPI context, but since I already have both of those, it would be better to credit this to ROS Constitutional
*There has been no blood or mucous in the watery stool or vomit*. Once again, this could be HPI Assoc. Signs, and HPI Quality (watery stool), but I already have 4 HPI counted. So instead, I'd count this under ROS. (I have to admit, though, I'm not 100% sure where I'd count it - probably under Heme/Immun/Lymph, but that _might_ be a stretch.)
*No other family members are ill yet. *This could be HPI Context, but it could also be PFSH - Family, so that's what I'd count it under
*He hasn't traveled outside of this area or changed his diet significantly.*Once again, could be HPI Context or PFSH - Social. I'd count it as PFSH.

Just balance your criteria. You're either going to have less than 4 HPI, or more. If you've got an abundance of HPI like I did with that note, then count your 4 elements, and count everything else somewhere else. Count it in a way that produces the highest result. If you're barely going to hit 4 HPI, or it's clear that there's not going to be 4 HPI, I'd only count 1 HPI and put the rest elsewhere. Since all 3 areas of History have to meet or exceed a level for the overall Hx to meet that level, the whole history is only as good as the weakest category. Don't worry about getting more than 2 ROS if you can't get 4 HPI, or if there's no PFSH whatsoever. (Just as an example)

I also found this extremely useful in learning E/M - it really helped me to balance the history.  http://trailblazerhealth.com/Publications/Job Aid/coding pocket reference.pdf

If you need any help with specific stuff in the book, let me know. I don't have that edition, but I learned on my own with the 2nd edition, and I know how frustrating it can be to not be sure if you're learning it correctly or not.


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## Captain74

Thanks Brandi.  I am confident in how to pick the HPI and ROS, but the problem is proving that what is counted in the HPI can't be counted again in the ROS.  I am just going to stand my ground and use the AMA info by Grider.

Thanks


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## btadlock1

Captain74 said:


> Thanks Brandi.  I am confident in how to pick the HPI and ROS, but the problem is proving that what is counted in the HPI can't be counted again in the ROS.  I am just going to stand my ground and use the AMA info by Grider.
> 
> Thanks



This may clear it up for you: http://www.acep.org/content.aspx?id=30474

(For the exam, stick with Deborah's advice. As far as actual auditing after that, I'd go by whatever guidance you MAC has to offer.)


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