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E/M ROS coding question

jsalzer50

Networker
Messages
67
Location
Vancouver, WA
Best answers
0
Hello fellow coders!

Just a quick question regarding the ROS when assigning E/M codes:

The patient is intubated.

For the ROS, does the information obtained from the medical chart and wife count for ROS?

Usually, we know ROS is subjective information from the patient, but in this report: "The patient is intubated and on a ventilator, so I do not have a good family history, social history, past medical history, past surgical history, or review of systems. I got some things from the chart and some things from his wife..."

Thanks in advance-----

- Jacob
 

mitchellde

True Blue
Messages
13,538
Location
Columbia, MO
Best answers
2
Since the patient is intubated and cannot communicate, the History is comprehensive. The information obtained from the wife goes under complexity of information in the MDM
 
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