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History of Present Illness and Your Medical Billing

History of Present Illness and Your Medical Billing

When to combine history of present illness and review of systems causes a lot of confusion among many practices. However it is possible to do and is perfectly acceptable to document an element once to account for HPI and ROS.

In many instances, 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. The physician is missing out on some additional revenue by not documenting the ROS. The CMS states that physicians do not need to document an element two times for medical billing purposes. It is perfectly acceptable to use one element for both.

However, there is one situation 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.

Also, watch your timing phrases that are used. 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 bill must more exacting in the documentation.

Combining HPI and ROS is possible in medical billing, but there are some guidelines. Your medical billing partner knows exactly what those guidelines are and the best way to get medical reimbursement for services rendered.

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