tci ED Coding & Reimbursement Alert - 2014 Issue 3

Documentation Guidelines: Those That Don't Study The Elements OF History Are Doomed To Repeat Them Under Audit

Brush up on the HPI and ROS components of history documentation to stay out of trouble. One of the areas of documentation guidelines that can be most confusing to new coders is the overlap between the history of the present illness (HPI) and the review of systems (ROS). Brushing up on your rules about who can document what and from where these history elements can be drawn can save you lots of hassles. Read on for some expert “history” tips. Who Can Record The HPI and ROS? It does make a difference who documents the HPI, says Todd...

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