Wiki Can I get ROS and History from HPI?

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jl2010

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"SUBJECTIVE: This is a 26 whte female, in today with complaints of right lower quandrant pain since this morning. She states that when she first woke up, she had noticed that her abdomen was quite tender. She has complained of chills all day. She has a history of a hysterectomy. "

I want to get ROS from HPI ------ GI(abdomenal pain) and Constitutional(chills)
and Hx ------ ( hysterectomy).

Can I do this? Thanks for any reply.

Judy --- CPC-A
 
Ros & history

You have to be careful with double dipping. So in my opinion, no, you cannot use that toward the ROS.

This would be my recommendation:
SUBJECTIVE: This is a 26 whte female, in today with complaints of right lower quandrant pain since this morning. She states that when she first woke up, she had noticed that her abdomen was quite tender. She has complained of chills all day. She has a history of a hysterectomy. "

HPI
Abdomen (location)
Since this morning (duration)
When she first woke up (Timing)
Chills (associated signs and symptoms) OR you could use this in the ROS under constitutional, but you can't use it in BOTH the HPI and ROS. You have to pick one or the other.

I would use the Hysterectomy as part of the past surgical history.


I hope this helps... :D
 
You don't need past surgical history

Before you need ANY element of the PFSH you MUST have at least 4 HPI elements and at least 2 ROS

From this statement I get
LOCATION: right lower quadrant
DURATION: since this morning
SEVERITY: quite tender (or you could call this QUALITY)
ASS SYMP: chills (or you could count this as ROS Constitutional)

ROS - GU - hysterectomy

Because you don't have 4 HPI AND at least 2 systems in the ROS, you don't even need to count PFSH.

I would not consider "when she first woke up" as timing. Timing refers to whether the symptom / complaint is constant, intermittent, regular, irregular. If the statement was something like "pain was sharpest when she tried to get out of bed" I would consider that context (i.e. movement made it worse)

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Last edited:
Check with your MAC

In another opinion, yes you can use the same information for both the HPI and ROS.

According to Highmark Medicare Services using the same information for the HPI, ROS and PFSH is not double dipping as it is all part of the History. Double dipping according to them would be using the same thing under the HPI or ROS for different elements - such as counting quite tender as severity and quality. So under their instructions, you could use chills as associated signs and symptoms and then also count it towards your ROS.

I would check with you carrier as to what they consider double dipping as you will get a number of different answers to your question.

Good luck!
 
Very good point, Jodi!

Very good point, Jodi. Yes, definitely check with your MAC.

HOWEVER ... this is a 26-yo patient, so is probably not covered by Medicare.

F Tessa Bartels, CPC, CEMC
 
I would agree to contact your MAC.

Trailblazer will noy allow credit for HPI and ROS with the same elements. In addition they do not recognize "All" or "Complete" in the ROS, they want all systems listed individually.

There are only 4 HPI and 1 ROS found in this note.
 
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