Radiology Coding Alert

Differentiate the HPI and ROS components of history documentation to beat any possible risks.

You need to ensure you are correctly interpreting the elements of history from appropriate sections of the clinical note. Do not confuse the history of the present illness (HPI) with the review of systems (ROS). Here is how you can save your practice from any setbacks due to wrong interpretation of history. 

Who Can Record The HPI and ROS?

It does make a difference who documents the HPI, says Todd Thomas, CPC, CCS-P, President of ERcoder in Edmond, OK. The 1995 and 1997 Documentation Guidelines have a specific statement on who can obtain/document a patient’s history that reads, “The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there should be a notation supplementing or confirming the information recorded by others.”

Conspicuously absent from that statement is mention of the HPI, Thomas says. Guidance from CMS officials and individual CMS contractor’s policy statements indicate that the physician or qualified Advanced Practitioner must personally perform the HPI. It is usually a statement more or less in the patient’s own words recapping the details of what brought them into the ED for the chief complaint. Elements of HPI include a description of the location, quality, timing, duration, context, modifying factors and associated signs and symptoms that can help diagnose the current problem and formulate the proper treatment plan, he explains.

ROS Can Be Recorded By Ancillary Staff

Unlike the HPI, which describes the present illness, the review of systems helps define the problem, clarify the differential diagnosis, identify any needed testing, or serves as baseline data on other systems that might be affected by any possible management options.

ED nuance: Because most ED patients are new to the treating physician with new emergent problems, the ROS obtained may be more extensive than in other clinical settings. A reasonably thorough ROS will help guide the evaluation and management of the patient encounter. As mentioned before, the ROS can be documented by ancillary staff, with physician notation that it was reviewed and confirmed.

CMS and CPT® list 14 systems that can be reviewed; however, CMS Documentation Guidelines state that after all pertinent positives and negatives have been addressed with individual documentation, the statement “all other systems are negative” meets CMS documentation requirements for a complete ROS in covering the systems with a negative response, Thomas explains.

According to the CMS documentation Guidelines, there are three different levels of ROS, and you must identify ROS level before choosing the overall history and the resulting E/M code level. These are as follows:

Problem pertinent - When the physician reviews a single system, this is a problem-pertinent ROS. This level of ROS can only support up to a level-three E/M (99283, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of moderate complexity ...).

Extended - When the physician reviews two to nine systems, this is an extended ROS. This level supports up to a level-four ED E/M (99284, … a detailed history; a detailed examination; and medical decision making of moderate complexity ...). (Note: This does not mean that all extended ROS encounters are 99284s; the extended ROS makes 99284 possible, but does not guarantee it.)

Complete- For a complete ROS, most insurers accept a review of 10 or more systems, With a complete ROS, reporting 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components with the constraints imposed by the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; medical decision making of high complexity ...).

Big caveat: Check payer ROS requirements before coding. Despite the CMS instruction about 10 ROS elements, some payers follow the CPT® description which states “review of systems directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems.” These payers will expect that the physician has documented a review of all body systems so that all 14 systems are addressed in the medical record, warns Thomas.

Verse Yourself on the Double Dip Dilemma

Perhaps the most controversial aspect of the HPI and ROS is whether you can draw HPI and ROS elements from anywhere in the chart and whether you can count the same documented elements as both areas of history.

Although it is true you cannot use a single item twice within the same section of the history (either HPI or ROS), CMS is on record as saying that you may use a single item in two separate historical sections; that there is no benefit from having to document the history element twice, says Thomas. For example, “constant” in the statement “constant back pain” could not be credited for both duration and timing in the HPI. However, in the statement “chest pain with shortness of breath,” “shortness of breath” could be credited as an associated sign and symptom in the HPI and also credited in the Respiratory system of the ROS for the same record, he adds.