ACEP ID:

HPI-ROS FAQ

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?

Will the documented phrase or templated chart check off box "all other systems reviewed and negative" suffice in meeting the ROS requirements for a complete review of systems?

What is the purpose of ROS?

What are Medicare’s rules or restrictions for documenting the History of Present Illness (HPI)? Can a nurse or other ancillary staff document the HPI for the physician?

Can the "status of at least three chronic or inactive conditions" be used to support an Extended History of Present Illness even though we follow the 1995 Documentation Guidelines?

Updated March 2021

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors, or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising from the use of such information or material. Specific coding or payment-related issues should be directed to the payer.

For information about this FAQ/Pearl, or to provide feedback, please contact Jessica Adams, ACEP Reimbursement Director, at (469) 499-0222 or jadams@acep.org

[ Feedback → ]