Wiki Help with Self Auditing?


Brewer, ME
Best answers
Hi Guys!

I'm going to attempt our first self audit and I'm getting caught up in the history portion of the history, exam, mdm. We have our patients fill out a PFSH questionnaire and it also asks if they have now or have ever had a history of... and it includes things like thyroid d/o, ulcers, diabetes, allergies, depression, colon problems, high blood pressure, etc. Our chart form lists the HPI, we have the seperate PFSH that the pt fills out, in addition to one our MA/RN fills out, and then the Exam and the MDM.

My question is- does any of this go towards the review of systems? The physician does his actual exam, but I'm trying to figure out what exactly the ROS in the History portion should be?

And the other part of this is: If my physician reviews 8 systems: Constitutional, Neck/Thyroid, Resp, Cardio, Chest, GI, GU, Psychiatry is that TECHNICALLY 8 systems, even if only 3 of them are pertinent (for example: pt requests permanent sterilization via Essure procedure- pertinent systems are Constitution, GU, and Psychiatry. I question if the 8 system review counts, or if I should be looking at the RELATED systems. Otherwise he could look at everything and level very high for the Exam portion. It seems to me I should be looking at the pertinent systems, not every single one giving him a point. Do you know what I mean?

Self Auditing is hard! I feel like it is variable as to what a person considers relevent. Any thoughts?
Self auditing

I see this alot where the providers mix and match the ROS and PFSH.

The ROS is a series of questions and are as a rule of thumb symptoms.
What you have list are all illness therefore they would all go in the past medical history.

If you take a look at the 1997 DG for GU female, you will see some of the systems do not have any "Elements of Examination" (ie Musculosketetal, Head/face, Eyes, ENTM, and extremities)...the reason for that is those system/body areas are not an intregral parts of this system. The provider would have to indicate the medical necessity for examining these systems.

Keep in minde - The presenting problem must support the level of service. Medical necessity is the overarching criterion for payment. The amount of documentation should not be the primary influence upon which a specific level of service is billed. Code selection of the reviewer is based on the nature of the presenting problem.

Enjoy...auditing can be challenging, but alot of fun.

Cheryl CPC, CPMA
I agree with Cheryl. There is a lot of incorrect cross usage of PFSH into the ROS.

CMS specifically states that past medical history can not be used as ROS.