Review of systems

Unspecified and other symptoms can't consider for both HPI and ROS: There are 14 systems recognized by the Centers for Medicare and Medicaid Services:[2] The questions may be asked of the patient in a "head to toe" manner.

There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them.

Double dipping may increase revenue by making it possible to qualify for a higher level of history and as such be considered fraud or abuse.

There is a fine line between the signs and symptoms that patient shares in the HPI and those obtained via the ROS.

For example: if the documentation reads "'patient states that her hip has been painful' credit is not given in both the HPI 'location' and to the MSK (musculoskeletal) review of systems."