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ROS,PFSH / E&M Chart Audit Question


Best answers
Good Afternoon!

I am in the middle of an internal chart audit on a patient referred to us by another physician. We rec'd the medical records from the other office incl. the ROS, PFSH.
Our office simply reviewed this information rather than obtain new documentation for our medical record. As for the audit, I do not feel I can give credit for those two components of the History due to the fact our doc did not actually obtain / document this information. Would you agree?

Vicki Durden
Lake Eye Associates
Milwaukee WI
Best answers
I would count it

If your physician documented having reviewed the ROS and PFSH provided by an "outside source" then I would count it ... AS LONG AS ... the medical records were from a reasonably recent time frame (within 6 months). If they were older records I would still count it if the physician documented that s/he reviewed the records and noted any differences/changes since the last report.

Hope that helps.

F Tessa Bartels, CPC, CEMC