Wiki Hpi & ros

[ksanthony]

Just covering myself when I go to the physician. For a complete ROS in the HPI you need at least 10 systems reviewed and not 10 positive and/or negative responses in less than 10 of the systems reviewed.

 

[sbicknell]

HPI, ROS and PFSH all make up the History component of the E&M along with exam and MDM

Guidelines for ROS state 10 ROS must be documented to meet a Complete ROS. For an Extended ROS, 2-9 systems must be reviewed

And the review must be made of each individiual system. If found normal the physician can document "negative" or "none noted" etc

If the system idenitifies a problem, then the physician must document detail of the identified problem. In other, words he can not document Respiratory-abnormal he must document what the abnormal finding or problem is such as Respiratory- congested cough

Also, check your Medicare payer (FI) and see what their guidelines are regarding the "all others found negative" statement. There are different views on this between payers