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E/M ROS coding question


Vancouver, WA
Best answers
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


True Blue
Columbia, MO
Best answers
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