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Family Practice Coding Alert

Reader Questions:

Tally History Elements

Question: May I count the organ systems in both the HPI and the ROS?

California Subscriber

Answer: Yes, the directions from the original "audit form" for Medicare state that you may count the review of systems (ROS) from systems listed in the history of present illness (HPI) and the ROS section of the note, if any. In practical terms, a physician would have to be allowed to count systems in both areas to get appropriate credit for his work in complicated cases.

For instance, a physician asks about five or six systems in the HPI of a complex case and must list 10 more systems in a separate ROS to qualify for a complete ROS (1995 Documentation Guidelines require 10 out of a total 14 organ systems). No method exists for reporting a comprehensive history (99204-99205, Office or other outpatient visit for the evaluation and management of a new patient ; and 99215, Office or other outpatient visit for the evaluation and management of an established patient ) because only 14 systems exist. In this situation, unless you can count the systems in both places, the physician has no way to get full credit for the complexity of the case.