Wiki Auditing E/M question

[codegirl0422]

I have always understood that elements within ROS can not count in the exam, even if there is no double dipping going on of the elements. But recently, I was told by several other certified coders that you can. I have always understood history to be provided by the patient and the exam provided by the doctor's observation during the encounter. That they would have to be documentated separately within in the note. My understooding is that the only place where elements can count in different sections is within the history (HPI, ROS, PFSH) as long as you are not double dipping.

 

[007CPC]

Hey codegirl

How's it going codegirl!

Your E/M question is quite a conventional one that I use to ponder within the first months of auditing ER-EM back in 2005. The context in which you could take a ROS subelement and place it in the exam subelement is all really determined by the severity of the condition your coding; e.g. If you were coding a case in which level of service was tottering between a 1,2 or 3, you wouldn't take the element from ROS. But if the severity of the condition were tottering between a 4, or 5 to a Critical care plateau it would be appropriate. Then again it all really depends on the mythology you're coding from. Since E/M varies from facility mythology quite extensively, I would code the way your superior wants it coded. If you are a superior, then I would check with who ever tells you what guidelines to code by. I never reached that superior plateau.

Hoped this helped

neuropathy

 

[khaspert]

ROS vs Exam

A review of systems is part of the history and is documented based on questions and the answers to those questions given by the patient. The provider is not examining anything. I would never use an element from the ROS for points in the exam. I have never even heard of this.

I would advise against it.

 

[codegirl0422]

A review of systems is part of the history and is documented based on questions and the answers to those questions given by the patient. The provider is not examining anything. I would never use an element from the ROS for points in the exam. I have never even heard of this.

I would advise against it.

That is what I thought. That is what I interrupted in numerous conferences that I have attended this past year. I was just wanting others view on it. As I understand it, the ROS can be done by ancillary personal so I couldn't see how I could use it in the exam. I know the doctor has to sign off on it but like you stated, the provider is not examing anything.

Thanks for your advice
codegirl0422

 

[007CPC]

Yea

Unfortunate for some of us who became professionals in an unconventional, unethical mythology. Not everyone gets a fair shoot through coding. Some rise, most others fall.