• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Chart Auditing - ROS

M

mbdk1977

Networker
Messages
26
Location
Somers, CT
I have recently completed an audit of some E/M codes and the group has a ROS, PFSH form. The patient and physician are most often times signing it but they are leaving it blank. Would you take that as having completed the review?
 
I agree with you, Lisa. It's hard to give credit for blanks. I know there are times when it's difficult to obtain this information (dementia, unconsciousness) but in normal circumstances, I feel an effort needs to be made. PFSH and ROS aid in the building blocks of the level of the e/m.

The ROS obtained on a previous visit does not have to be re-recorded, but all new information must be documented along with a notation stating where the previous information is located in the chart. Also, a review of the PSFH obtained during a previous visit does not have to be re-recorded but, again, new information must be listed along with a notation regarding the location of the previous PFSH.

Some type of documentation is needed to record pertinent facts, findings and observations about a patient. The physician will be held accountable for his documentation and as stringent as carriers are becoming, it's in his/her best interest to supply this information; but this only my opinion.
 
I am new to this practice - OB-GYN - and am expected to begin chart audits. I do not have any experience with this. Does anyone have any reference information they could pass along to me?
i.e web sites, publications, etc.?
Thanks!
 
OB-GYN chart audits

Lana, you definitely want to get some OB-GYN specific chart audit training if you haven't done this before. You might check out the American College of Obstetrics and Gynecologists' Coding and Nomenclature web page http://www.acog.org/departments/dept_web.cfm?recno=6 and see if there are any chart auditing seminars/workshops near you that you could attend for some specialty-specific audit training. The AAPC might also sponsor chart auditing workshops that also provide CEUs so check with them too. Good luck!

LanaW said:
I am new to this practice - OB-GYN - and am expected to begin chart audits. I do not have any experience with this. Does anyone have any reference information they could pass along to me?
i.e web sites, publications, etc.?
Thanks!
Click to expand...
 
You must log in or register to reply here.
Top