cerullhon
Contributor
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!
Any comments would be appreciated!