Wiki Review of Systems - records and labs count

reinelt

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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?
 
no, think of a review of systems as a review of "symptoms." These are subjective statements from the patient (e.g., no chest pain, no SOB, no fever, etc). The provider is credited one point for ordering or reviewing a CT scan result under the data section of MDM. Or, if the physician personally reviews the scan (and not just the result written by the radiologist), he/she can get 2 pts.

Do you have an E/M abstraction worksheet?

Lisi
eharkler@nm.org
 
Review of Systems is the physical exam. But I will let the doctor know about the 1 and 2 points. Thank you for your help.
 
The "review of systems" is not the "physical exam". If you are coding this way then this is a huge error and everything coded has been incorrect.
 
ROS documentation combined with Physical Exam

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.
 
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.

I don't believe so. Maybe he means for subsequent visits?
 
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.
 
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.

Here's the best explanation I could find on the difference between ROS and PE...I know you said you've given him info previously, but possibly try once more?

http://www.medicalcoding123.com/2012/09/ros-vs-physical-exam.html

The only other point I can think of, is that some MAC's/payers will allow elements from the HPI to be used in the ROS. You'd have to check with your region's MAC for clarification though. Here's Novitas, as an example (see #15):

http://www.novitas-solutions.com/we...f.ctrl-state=g6dbl44pl_84&contentId=00005056#!
 
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