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No Review of Systems documented

C

ChristineA

Networker
Messages
49
Location
Saint Joseph, MO
My physician saw an inpatient in the ICU and was unable to obtain a ROS as patient was on a vent and in acute respiratory failure. Can you still bill a level 5 or do you have to have some type of ROS.
 
ChristineA said:
My physician saw an inpatient in the ICU and was unable to obtain a ROS as patient was on a vent and in acute respiratory failure. Can you still bill a level 5 or do you have to have some type of ROS.
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I posed that same question to my MAC and was informed that you can count the ROS as long as you document why it was unobtainable but the level would be dependent upon the rest of the documentation and/or the severity of the pt in question.
 
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