EM Coding Alert

Reader Question:

Keep HPI, ROS Separate in E/M Calculations

Question: For an E/M visit, if the physician states ROS as noted in the patient’s HPI, can you count the diagnoses in the HPI toward the ROS?

Maryland Subscriber

Answer: Simply put, the answer is no. The review of systems (ROS) is a documented account of the patient’s responses to an inventory review of various body systems. The provider should not take notes documented as a part of the patient’s history of present illness (HPI) and incorporate them into the ROS portion of the E/M visit.