1995 vs 1997 ROS

dwobig

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Can anyone tell me if there is any difference in the 95 vs 97 guidelines when it comes the ROS? I have a copy of the 97 guidelines, and it looks lke the same rules apply as in the 95 guidelines.

A problem pertinent ROS inquires about the system directly related to the
problem(s) identified in the HPI.

The patient's positive responses and pertinent negatives for the system
related to the problem should be documented.

An extended ROS inquires about the system directly related to the problem(s)
identified in the HPI and a limited number of additional systems.

The patient's positive responses and pertinent negatives for two to nine
systems should be documented.

A complete ROS inquires about the system(s) directly related to the problem(s
identified in the HPI plus all additional body systems.

At least ten organ systems must be reviewed. Those systems with
positive or pertinent negative responses must be individually
documented. For the remaining systems, a notation indicating all other
systems are negative is permissible. In the absence of such a notation,
at least ten systems must be individually documented.

We are using the 97 guidelines for our surgeons, and when he sees a patient in the ER for a consult for a specific problem, (eg), I & D, or hip fx, and documents no ROS. What level would be appropriate for his consult?

Another point, If the surgeon states he reviewed the ER Dr notes, who did a full ROS, could this be counted towards his level, and if so how do you count that?

Thank you,
Debbie
 
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codegirl0422

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I believe ROS is the same for both 95 & 97, HPI is different. I have been heard in several conferences and documentation backs it up: if you choose to use the status of 3 chronic medical problems you will need to use the 97 guidelines. 95 guidelines you must use the HPI elements. Both for ROS I do not see any differences.

You can go to the CMS website and there is E/M guide, I believe it is under the MLN products. Plus the www.emuniveristy.com & the www.intelicode.com have alot of useful info on E/M visits.
 
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