ROS and Physical Exam components

[krssy70]

A patient is an established patient. The physician saw the patient a week earlier and documents that the ROS and Physical Exam is unchanged from the previous visit. What can I count for this incomplete note??

Any Help????

 

[SuzanBerman]

The Review of Systems can be referenced if there has been no change. However, the physical exam needs to be repeated, and thus documented. It cannot be referenced.

Hope that helps.
Suzan

 

[krssy70]

Thanks Suzan, Thats what I thought. Appreciate your response.

 

[RebeccaWoodward*]

A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a
physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

• describing any new ROS and/or PFSH information or noting
there has been no change in the information; and

• noting the date and location of the earlier ROS and/or PFSH

If the above criteria is met, you can allow this information. Also, keep in mind...the previous ROS needs to be medically necessary for the follow up visits(s). Referencing a full complete ROS for every visit may not be medically necessary...

http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf

 

[abc1099]

I have one physician in our practice, though, who will say visit after visit, ROS unchanged from (gives previous date) which can take you back maybe a year to the original dictated ROS. I don't feel this is appropriate. Any thoughts or comments would be appreciated.

Ann Campbell, CPC

 

[FTessaBartels]

ROS unchanged from last visit.

That is why I love the patient questionaire that is completed annually. You always have something to reference that is "relatively" current.

Remember, too, that if you dealing with an established patient you only need two out of three key elements.

So you might be able to reach the appropriate level of service with exam and MDM without any history elements. And if you NEED history ... a 99213 only requires a "problem pertinent" ROS ... so saything there are no changes since the last visit certainly qualifies in my book. (Of course you still need the chief complaint and brief HPI.)

Hope that helps.

F Tessa Bartels, CPC, CEMC