Documentation Guidelines: Those That Don't Study The Elements OF History Are Doomed To Repeat Them Under Audit

Why This Topic Matters

History documentation is a frequent audit focus, and misunderstanding how HPI and ROS are captured can affect the supportability of E/M code selection. The article helps readers recognize the general documentation areas that create risk and where payer policies may differ.

Article Sections

1. Who Can Record the HPI and ROS?

   Discusses general documentation responsibility for history elements and the distinction between what different staff types may record. It also references CMS-era documentation guidance and the role of physician review.

2. ROS Can Be Recorded By Ancillary Staff

   Covers the role of the review of systems in the history and its use in evaluation and management documentation. The section also introduces general ROS levels and payer-related considerations tied to system review breadth.

3. Verse Yourself on the Double Dip Dilemma

   Addresses the broader issue of whether history elements may be drawn from multiple parts of the record and whether the same element may appear in more than one history component. It frames the topic as a documentation and audit concern.