# History and Physical w/o ROS



## Trendale (Feb 19, 2009)

Hello,
Can someone tell me if the ROS is missing from the H&P, can this  be coded down to an expanded problem focused visit/ problem focused? The Physician documented the HPI and the PFSH but no ROS. The physcian also documents labs which shows results pertinent to the patients condition. Can I use some of the lab info to indicate a ros pertinent to the problem?, otherwise this would be a problem focused visit, because there is no ROS documented and I have to code to the lowest. 
Thanks in advance!


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## jhanak (Feb 19, 2009)

*reply to no ros*

According to the cpt manual only 2 of the three components have to be met to use a 99213. You have a expanded problem focused history, and medical decision of low complexity. I think you can use the 99213 (if we are talking about a established patient).


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## FTessaBartels (Feb 19, 2009)

*99221 Needs DETAILED History*

For the lowest level of Hospital Admit you need a Detailed History:
*Chief Complaint*
*HPI *w/ 4+ elements (or status of 3 chronic conditions)
*ROS* of at least 2 systems
*PMFSH* - at least ONE of these areas needs to be documented.

So ... if your doctor didn't complete any ROS but did include a past medical history AND either family and/or social history ... see if you can take the info from the past medical hx and for at least 2 systems of ROS.

If the documentation won't allow that, then you should code the unlisted E/M 99499.

F Tessa Bartels, CPC, CEMC


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## Trendale (Feb 20, 2009)

*Reply to H&P w/o ROS*

Thanks for the response. This visit would be an initial hospital care visit, as the physcian admitted the patient. The physcian documents " as I mentioned in the history of present illness". The HPI includes: HTN, CAD, Hyperlipidemia, CHF, and COPD. The physcian also states patient came in office with extremity pain and increasing SOB. Patient was noted to have an O2 sat of 80%. Was then transferred to the emergency room. So can I use some of this information to substitute at least 2 ROS? If so, then I should be able to code this as a 99221. Thanks!


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## FTessaBartels (Mar 5, 2009)

*Double dipping*

You can't double dip by counting the HPI elements again as ROS ... BUT ..
since you seem to have enough HPI with the HTN, CAD, Hyperlipidemia, CHF, and COPD, then YES, I'd count the extremity pain and SOB as 2 ROS elements.

NOTE: For the HPI, he has to have included the *STATUS* of the chronic conditions - improved, worsening, stable, unstable, continuing  - something on that order. Just listing the conditions isn't enough to qualify for "status of 3 or more chronic conditions."  

Hope that helps.

F Tessa Bartels, CPC, CEMC


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