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Wiki new coder needs help with ROS

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ggparker14

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Physician says he can't do ROS on 3 year old because of age and also documens HENt: negative for ear pain. Can this be counted as comprehensive or is it only correct to count the one system?

Thanks for any help.
 
I'm thinking that 3 year old probably had a parent he could have gotten a ROS from.

I'm not sure what you are asking on your second question..do you mean for an exam? I count HEENT as one system.
 
rhblevins61@yahoo.com said:
Physician says he can't do ROS on 3 year old because of age and also documens HENt: negative for ear pain. Can this be counted as comprehensive or is it only correct to count the one system?

Thanks for any help.
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The question is how many systems are in this statement " HENt: negative for ear pain" It is one.
However...
If the provider stated, "HEENT without complaints" this would count as 2 systems. This abreviation stands for head, eyes, ears,nose and throat. If you review the ROS from CMS eyes and ears are the 2 systems. https://www.cms.gov/MLNProducts/Downloads/1995dg.pdf page 7

The tricky part is how you use the 'head' part of HEENT.
 
I agree with all of the above and the only thing I can offer is that I sometimes use the HEAD as musculoskeletal... ie. head normocephalic, symmetrical, etc.
 
I agree with Dee CPC, HEENT is definitely 2 different systems. I guess if the ED MD meant head, eyes, nose and throat when he put HENT, then you can count it as two. ENT (ear, nose and throat, which includes the head I believe) is one system, but the eyes are totally separate. So if he meant eyes, and not ears, you can count 2.
 
Peapod, that is too what I was taught by a MD who was also a CPC but not all auditors have agreed with that.

Also, if he says "HEENT : negative for ear pain" I would only use this as one. S/he isn't saying anything about the other areas.

Am I picky? I would encourage the Doc to say "negative except ear pain"
 
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