Pediatric Coding Alert

Question: For a chart with a chief complaint of resolving pneumonia, a note indicates, "No coughing, SOB." Should I give the pediatrician credit for this statement under history of present illness (HPI) or as a review of systems (ROS)?

Michigan Subscriber

Answer: This is a gray area of E/M coding that you can count under either history type. You could give credit for "no coughing" and "no shortness of breath" (SOB) as associated signs and symptoms under HPI. Some auditors might instead count the notation as a review of the respiratory system under ROS.