Abstracting ROS from Physical Exam

cerullhon

Contributor
Messages
19
Best answers
0
I have a provider who does not document "ROS". This causes New Patients to be down-coded to Subsequent as the "3/3" rule is not being met. This provider is now saying we should abstract the "ROS" from the Physical Exam because all information is contained therein and no need to further document "ROS". This is "double dipping" as we can't use elements twice from one category to the next. We have provided information from many sources that all components of an Exam must be documented clearly.
Any comments would be appreciated!
 

LuckyLily

Guru
Local Chapter Officer
Messages
112
Best answers
0
You can abstract the ROS from the HPI. You are correct that you cannot us the Exam to do this. Within my study guide for the CEMC exam it states, "ROS may be supplied in any format including a separate patient intake or questionnaire form. It is commonly interspersed with elements of the HPI." You are correct that you can't double dip. There has to be enough documentation within the HPI to grab both the HPI elements and the ROS elements. The example given in the book is, "the patient states that she has a sore throat. She denies any postnasal drip or fullness in her ears when she swallows," there is a distinct component of both HPI (location-throat) and also the separate ENT system review.

I agree that the Dr. should do a complete ROS for a new patient. Maybe you should present it that for a new patient it is more medically necessary to have a complete ROS and the followup appointments to get the ROS from HPI.

Hope this helps.
 

thomas7331

True Blue
Messages
3,146
Best answers
8
The ROS and exam are two completely different things - ROS is the patient's responses to questions about their symptoms and the exam is objective findings of the provider. If the provider is documenting ROS within the body of the exam, then it would be fine to count those as ROS but you can't count exam findings as ROS or vice versa.
 

maddismom

Guru
Messages
180
Best answers
0
The ROS and exam are two completely different things - ROS is the patient's responses to questions about their symptoms and the exam is objective findings of the provider. If the provider is documenting ROS within the body of the exam, then it would be fine to count those as ROS but you can't count exam findings as ROS or vice versa.

If the provider is documenting ROS within the body of the exam, then it would be fine to count those as ROS? You are contradicting yourself. Please clarify what you meant.
 

thomas7331

True Blue
Messages
3,146
Best answers
8
It's not contradictory - you would just count the elements for what they are. So if the provider dictated in the exam section "normal breath sounds, patient denies any difficult in breathing", you could count both exam (breath sounds examined) and ROS (no symptoms per patient's response). Does that help?
 
Top