HPI-ROS FAQ

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.

For example, "Nightly," in the statement 'nightly leg pain' could not be credited for both duration and timing in the HPI. However, in the statement 'chest pain with shortness of breath', "shortness of breath" could be credited as an associated sign and symptom in the HPI and also credited in the Respiratory system of the ROS for the same record.

CMS 1995 and 1997 Documentation Guidelines both state that after pertinent positives and negatives have been addressed, the statement "all other systems are negative" meets CMS documentation requirements for a complete ROS.  Physicians are reminded that pertinent positive or negative responses should be individually documented.  When a complete ROS is performed, the statement "all other systems are negative" is permissible for systems with a negative response.

Some payers have expressed concern that the ROS caveat may be over-utilized, especially for visits with lower levels of medical decision making where documentation of a complete ROS is not required.  In addition, some Medicare contractors have proposed variations to the documentation of ROS.  Specifically, some contractors do not accept the statement "all other systems are negative" as sufficient to support a complete ROS.  Members are advised to be familiar with local requirements.

CPT states:  "The review of systems helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options."  Given the absence of continuity of care for patients in an emergency department setting, the ROS obtained may be more extensive than other clinical settings.  A reasonably thorough ROS will help guide the evaluation and management of the patient.

"The only definitive statement in the 1995 and 1997 Documentation Guidelines regarding who can obtain/document a patient's History states: "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others." Verbal guidance from CMS officials and individual CMS contractor's policy statements indicate that the physician or qualified NPP (Advanced Practitioner) must perform and document the HPI.  For guidance on documentation requirements for residents, Advanced Practitioners (NPP's), or scribes, please refer to the relevant FAQ.

Historically, a provider must choose to follow either the 1995 Documentation Guidelines or the 1997 Documentation Guidelines, but not a combination of the two. However, CMS released an update that states for services performed on or after September 10, 2013 physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service.