reinelt
Contributor
Does looking at a CT result for a head CT count as a ROS? Also, does looking at data points like old records and labs count towards the E/M calculation?
This is for In Patient Hospitalist coding. Can the ROS documentation be combined in with the Physical Exam? My Provider does not have a "ROS" heading, but states the ROS is combined in the Physical Exam.
No, these are new In Patient Hospital Visits. His documentation is all over the place and sometimes he doesn't list the ROS. Due to the 3/3 rule, we can't credit him for a New Visit and have to downcode to subsequent. However, he states the ROS is within the body of the Physicial Exam (it isn't_). Even if it was, "double dipping" is not allowed in any of the E/M components. We have even provided documentation from CPT book, Wikipedia and and info from a E/M seminar we attended given the definition of "ROS".
I'm at a loss of what else to do.