Review of Systems: Its importance in Medical Billing

Combining history of present illness and review of systems is possible when doing medical billing. Many medical billers think this practice is breaking a rule or impossible. However, documenting an element once to account for HPI (history of present illness) and ROS is acceptable medico-legally when done correctly.

CMS states that physicians absolutely do not need to document an element two times just so the person performing medical billing knows it is meant to be used both for review of systems and history of present illness. It is perfectly acceptable to use an element for both.

The only time an element cannot be used in duplication is when you attempt to use it in the same area. For example, the complaint of chest pain cannot be used in ROS (review of systems) for musculoskeletal systems and the cardiovascular system. It can be used only for one location in the medical billing.

A medical biller also cannot use a timing phrase such as "began a couple of days ago" to account for both the HPI (history of present illness) duration and timing. Direct medical documentation must be used.

According to Dr. Jitesh Chawla, healthcare expert, the most important thing to accomplish in medical billing is to make the bill match the service that was actually given. With the increasing adoption of EMRs and Health IT this becomes much easier.When this occurs, payment is made quicker. Medical billing companies can assist medical practices with this task. Outsourcing your medical billing be beneficial for your practice, however, better yet is to use an EMR that has an integrated PM (practice management )/ Billing system that can send statements directly to the payer. This takes the worry off correctly coding and billing by manual means and physicians will see reimbursements much more quickly.