When reviewing documentation of the evaluation and management ...

[joblessjake]

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?
 
  What will be an ideal response?

Question 2

Patient hyper extended her right thumb during a Roller Derby event last night. Application of ice reduced swelling, loose bandages immobilized damaged ligament, but patient presented to the clinic because the throbbing pain radiated along the length of her forearm at an 8 out of 10-pain scale. The documentation supports an extended history of present illness:
 
  Please read the following medical documentation and identify whether the stated history of present illness level is true or false.

[meganmoser117]

Answer to Question 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.

Answer to Question 2

TRUE

[joblessjake]

Thank you

[meganmoser117]

Happy to help you