• 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..

Wiki EM audit question for Ortho

Create Wiki
R

reichtina320

Guru
Messages
225
Location
Modesto, CA; Central Valley Chapter
Best answers
0
Hi,

In the HPI; if it is stated 'x-rays were unremarkable' can this be used as quality or severity?

TIA!

Tina
 
Thanks Lisa, that's what I was afraid of...he actuatlly documented it in the HPI and under imaging studies.

I would like to ask another question.....

In the HPI states 'parents do not note any specific problems' and then under ROS states 'unobtainable'. From what I understand, because he did not state why it was unobtainable it cannot be used for ROS. However, if he were to document under ROS - Complete ROS reviewed with parents who do not note any specific problems', would we be able to use this as a complete ROS?

Sorry for the silly questions but it has been a while since I have done ortho audits.

TIA?
Tina
 
Tina - if the parents are with the child, then a review of systems isn't really unobtainable, as it can be obtained from the parents, just as the HPI and PFSH can be obtained from the parents. As you know, a ROS is a Q/A with the patient - in this case the parents. The unobtainable situation would only be applicable in ED coding as a caveat. I would recommend that the provider note specific ROS rather than the blanket statement. So I guess my opinion is that I would not count this as a complete ROS unless some of the systems are documented with pertinent positives/negatives AND "all other systems are reviewed with the parents and are negative". The other issue is that I have heard that carriers are moving towards not counting the blanket statement "all others..." as complete in their audits. Perhaps someone else can confirm or refute this?? I think this is going to be an area of controversy for awhile...
Lisa;)
 
You must log in or register to reply here.
Top