When reviewing documentation of the evaluation and management service, who is responsible for determining which documented findings are most appropriate to support the review of systems, and which are more appropriate to support the history of present illness?

Question

What will be an ideal response?

Answer 1

The answer should include any (or all) of the following:
? The medical coder, compliance manager, auditor, or consultant reviewing the documentation must determine which documented findings support the ROS, and which documented findings support the HPI.
? Because the HPI elements are often considered "empathy elements," findings that support the HPI address the current chief complaint rather than any prior symptoms or complaints that are unrelated to the CC.
? Meanwhile, the ROS elements may be considered an "anatomical inventory," findings that support the ROS address the patient's previous state of health, and may not specifically relate to the chief complaint.
? Understanding anatomy can help determine which documented findings are most appropriate to support the ROS, and which documented findings are most appropriate to support the HPI, because it is easier to identify a correlation between the documented findings, the chief complaint, the patient's descriptions of the chief complaint, and the fourteen organ systems of the review of systems.