cpccoder2008
True Blue
We use the 1997 Guidelines, Can you use a bullet from both the ROS and the PE and get credit ?
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- Thread starter cpccoder2008
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cpccoder2008
True Blue
So if you use Constitutional in the ROS can you count it again for the PE ?
cpccoder2008
True Blue
I guess a better wording of the question would be, Can you count a bullet more than once ?
Ex:
HPI- 66 y/o female with abdominal pain. No fever or weight loss. General apperance is well maintained.
PE- General: No fever or weight loss. No acute distress.
Ex:
HPI- 66 y/o female with abdominal pain. No fever or weight loss. General apperance is well maintained.
PE- General: No fever or weight loss. No acute distress.
You can review the same system you examine, yes.
In your example
HPI- 66 y/o female with abdominal pain. No fever or weight loss (this would be cons ROS). General apperance is well maintained (this would be a cons exam bullet even though it is listed under HPI).
PE- General: No fever or weight loss (if the vitals are documented you could get the other cons exam bullet here). No acute distress.
Does that make sense?
Laura, CPC
In your example
HPI- 66 y/o female with abdominal pain. No fever or weight loss (this would be cons ROS). General apperance is well maintained (this would be a cons exam bullet even though it is listed under HPI).
PE- General: No fever or weight loss (if the vitals are documented you could get the other cons exam bullet here). No acute distress.
Does that make sense?
Laura, CPC
Coder2hear813
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There are three bullets for constituional exam bullet for my speciality(ENT):
[*]Measurement of any 3 of the following 7 vital signs:sitting or standing blood pressure,supine blood pressure,pulse rate and regularity,respiration,temperature,height,weight(May be measured and
recorded by ancillary staff)
[*]General appearance of patient
[*]Assessment of ability to communicate and quality of voice
ROS constitutional is if the patient reports weight gain,wieght loss, etc.
Hope this helps
Shana CPC, CPC-H
[*]Measurement of any 3 of the following 7 vital signs:sitting or standing blood pressure,supine blood pressure,pulse rate and regularity,respiration,temperature,height,weight(May be measured and
recorded by ancillary staff)
[*]General appearance of patient
[*]Assessment of ability to communicate and quality of voice
ROS constitutional is if the patient reports weight gain,wieght loss, etc.
Hope this helps
Shana CPC, CPC-H
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cpccoder2008
True Blue
so can i use it twice if only documented once ? Can i use Con in the HPI for a ROS and use it for PE ? My physician might write
HPI- 66 y/o female with abdominal pain.
PE-
General- No fever or weight loss.
Could i use one bullet for ROS and one for PE ?
HPI- 66 y/o female with abdominal pain.
PE-
General- No fever or weight loss.
Could i use one bullet for ROS and one for PE ?
If the documentation is only no fever, no weight loss the only thing that could be in my opinion is ROS. If there are also vitals, ie bp 120/80, wt 150, temp 98.6, then that is an exam element.
Bottom line, one statement can not be counted twice.
Laura, CPC
Bottom line, one statement can not be counted twice.
Laura, CPC
cpccoder2008
True Blue
So you can't use the no fever or weight loss as a bullet for Cons under the PE for General Apperance ?
FTessaBartels
Guest
Your specific question
cpccoder2008, You ask: so can i use it twice if only documented once ? Can i use Con in the HPI for a ROS and use it for PE ? My physician might write
HPI- 66 y/o female with abdominal pain.
PE-
General- No fever or weight loss.
NO ... you cannot use the exact same statement (documented only once) to count for both ROS and exam.
The physician MAY have documented two statements, one under HPI that patient had no complaint of fever or weight loss (which would count as ROS constitutional), and then the physician may have recorded the temp and weight (if using 95 guidelines, you'd still get a bullet for constitutional ... 97 needs 3 vital signs to get a bullet).
F Tessa Bartels, CPC, CEMC
cpccoder2008, You ask: so can i use it twice if only documented once ? Can i use Con in the HPI for a ROS and use it for PE ? My physician might write
HPI- 66 y/o female with abdominal pain.
PE-
General- No fever or weight loss.
NO ... you cannot use the exact same statement (documented only once) to count for both ROS and exam.
The physician MAY have documented two statements, one under HPI that patient had no complaint of fever or weight loss (which would count as ROS constitutional), and then the physician may have recorded the temp and weight (if using 95 guidelines, you'd still get a bullet for constitutional ... 97 needs 3 vital signs to get a bullet).
F Tessa Bartels, CPC, CEMC
cpccoder2008
True Blue
Ok. I think i'm understanding better now. I know that i can't use the same statement twice. But how do i determine if i can get a bullet from the constitutional for either ROS or PE ?? What makes the two different ? I am reffering to the 1997 Guidelines. What are some examples of constitutional ? I know for the PE three vitals count as one bullet and general appearance as another. BUt why would fever and weight loss only count towards ROS ? Couldn't weight loss be considered general appearance ? I have reviewed the E.M university site which is very helpful with examples but i can't seem to find any for constitutional.
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