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Wiki ROS Documentation

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jackiemal

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I need some guidance. We are being told that if the patient is a pediatric patient under the age of 18 we are to automatically give credit for a complete ROS. Can someone help me out with this? I thought that it was just if the patient was unresponsive, there was no where to get the information (past records or family/friend), and the reason it was unobtainable has to be documented. Can anyone can give me a good source to explain this? I refuse to give credit like this and I'm being penalized!

Thank you,
 
There was some discussion awhile back (unsubstantiated, by the way) that indicated you could get data points for obtaining history from anther person (parent) when treating a minor. Since this is typically the way all pediatricians obtain history information, there was the thought that this wasn't outside their normal E&M process, and it should be routinely counted as additional data points. However, I've never heard of obtaining a full ROS based on patient's age, only if the ROS is otherwise obtainable, and the reason is documented.
 
Thank you! We always have 3 or 4 bullets for a pediatric patients, either from the parent/guardian or the patient themselves. I don't think it is correct to give them a complete ROS. Unfortunately they won't stop penalizing me unless I can get something in writing from CMS or AMA. If anyone has any resources I would love to see it!
 
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