Combining HPI and ROS In Your Medical Billing

Combining HPI and ROS In Your Medical Billing Claims

Combining history of present illness and review of systems is possible when doing medical billing. Many medical billers think this practice is breaking a rule or impossible. However, documenting an element once to account for HPI and ROS is perfectly legal.

Many times a physician will leave a medical billing company with tons of documentation for a review of systems, but not enough information for the history of present illness. Don’t worry! There is no need to down-code.

The CMS states that physicians absolutely do not need to document an element two times just so the person performing medical billing knows it is meant to be used both for review of systems and history of present illness. It is perfectly acceptable to use an element for both.

There is one time when you cannot use the same element twice. That is when you are trying to use it in the same area. For example, the complaint of chest pain cannot be used in ROS for musculoskeletal systems and the cardiovascular system. It can be used only for one location in medical billing.

A medical biller also cannot use a timing phrase such as “began two days ago” to account for both the HPI duration and timing.

The most important thing to accomplish in medical billing is to make the bill match the service. When this occurs, payment is made quicker. Medical billing companies can assist medical practices with this task. It is beneficial to outsource your medical billing in order to receive the quickest and most accurate payments possible.

Combining HPI and ROS is possible in medical billing, but there are some guidelines. Medical billing companies know exactly what those guidelines are and the best way to get medical reimbursement for services.

View all Articles by: Melissa Clark, CCS-P