Wiki Chief Complaint versus ROS question

[jtb57chevy]

One of our billers just returned from a boot camp where she was told that the chief complaint cannot be addressed in the ROS. I am quite confused by this information and she, unfortunately, did not ask for documentation from the instructor. Can anyone shed any light on this for me? If the chief complaint is listed as "chest pain", can "chest pain" be listed in the ROS?

Thanks for any input!

 

[LLovett]

Maybe she got it backwards. You can't use the chief complaint as an ROS if it is only documented once but if they document say chest pain for chief complaint then also do a ROS and include chest pain then it would be counted for both.

Laura, CPC, CPMA, CEMC

 

[FTessaBartels]

Well ...

I had always believed it to be as Laura stated ... if you made the statement twice, you could count it twice.

BUT ... I've attended several seminars on E/M coding where this was strictly interpreted as "double dipping."

So if the chief complaint was "chest pain" Your ROS question would have to be something ELSE involving respiratory or cardiac or musculoskeletal or skin (if "chest" was really "breast") For example - ROS Patient denies any palpitations, shortness of breath, muscle strain, nipple discharge

This may also be carrier specific.

Hope that helps.

F Tessa Bartels, CPC, CEMC