Is this just a rule of thumb??????

[LewinFamily]

I am trying to get some assistance in finding some documentation that clarifies that the ROS or HX information must be dictated prior to the Examination and MDM section of a visit. I have been researching all day with no luck. Can you please assist me? I am doing a rather large audit and need supporting documentation for this issue. Thank you!

 

[jillmtom]

If the physician(s) you are reviewing are following a SOAP note format then yes, the CC, HPI, ROS and PFSH (these are the "S", subjective, portion of the SOAP note) needs to be documented before the exam and MDM. If you are reaching for ROS and/or HPI in the "AP", assessment and plan or MDM, then there is a problem with the formatting and flow of the information being documented.

You should suggest that they stick with the SOAP note format for consistency. That should also be part of the billing compliance plan for the office as to the formatting of documentation.

Good Luck!

 

[LewinFamily]

Okay thank you.. My only question is if they have the ROS after Examination can I still count that towards ROS or would that be invalid? Meaning if they have extended HPI, complete PFSH and allergies ONLY after HPI but the list of systems at the end of the note then that would make the visit expanded problem since I couldn't count the rest of the ROS information.

 

[FTessaBartels]

No rule

There is no rule that any of the elements have to be recorded in any order at all. Though it certainly makes it easier on the auditor to have it done "in order" - CC, HPI, ROS, PFSH, Exam, A/P. You take the elements whereever you find them (just make sure you aren't double dipping ... i.e. counting the same phrase twice)

The actual SOAP format is not really very helpful either as many forget elements of HPI, ROS, PFSH using it. (Dr Jensen on www.emuniversity.com recommends AGAINST the SOAP format.)

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[LewinFamily]

Okay.. Thank you.