Wiki E/M 97 Guidelines

[despinoza]

If a patient comes in for nausea and HPI for Chief of Complaint and then ROS for Gastro is done and nausea is located in that section, is that duplicating? Could it still be used for both HPI and ROS, or does it need to be worded differently?

Please help thanks,

 

[teresabug]

I was literally trying to find info on this myself literally minutes ago. I found this info on the acep.org site:
under FAQ:
FAQ 1. For documentation purposes under the Medicare E/M guidelines, can a single historical item be credited in both the HPI and ROS? For example, could nausea and vomiting be used as a symptom in the HPI and also be credited as a system (GI) in the ROS?

Some confusion exists over this issue. While it is true that a single item cannot be used twice within the same section of the history (either HPI, ROS or PFSH), it appears that a single item may be used in 2 separate historical sections. Based on correspondence with CMS representatives, ACEP believes that under the CMS documentation guidelines, the use of a single historical item in both the HPI and ROS is recognized as an acceptable practice. These letters can be viewed on the ACEP web site. As with many aspects of the documentation guidelines, individual Medicare contractor variation may exist and members are advised to seek clarification with local representatives."