No Review of Systems documented or done HELP!

bethb

Guru
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Pittsburgh Central Pennsylvania
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Hi.

I am looking for suggestions and input for this scenario. I am fairly new to E&M code reviews and am stumped on this.

A new patient presents to the office. I have read the documentation through and through and found that no Review of Systems was done. I asked the provider, who responded, states he did not do a review of systems. Pt is intellectually impaired and a poor historian. I have no idea now what this means for the History portion of the evaluation and management.

Is the history element booted down to problem focused because no ROS was done? I have not had a coding situation before where an ROS was NOT done.

Does anyone have any knowledge or suggestions? I'm stumped :(

Thank you in advance.
 

Chelle-Lynn

True Blue
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Location
Modesto, CA
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If the provider was unable to obtain a Review of Systems he would have to document in his records the reason that he was unable to obtain the ROS. Example:
* Patient was unable to speak due to xxxxxxxxxx
* Patient was intubated
* etc.

If the reason was not documented, then in your case, you would need to lower the E&M to problem focused.
 
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