Wiki ROS Question and Exam Bullet Question

[Stefanie]

Our clinic uses strictly 1997 Guidelines..
ROS:

1. Does anyone use "ALLERGIES; Sulfa" or "NKDA" as a ROS?

EXAM:
2. Provider states: "Patient is alert and oriented x3", is there anyway to justify using "alert" as a bullet in pysch? I know that oriented x3 is one, but when you only need one more bullet to reach a higher level...ya know...

3. When physician states "HEENT - Normal" how many bullets do ya'll give? I give 4, ears, eyes, nose and throat. Head is only counted if you include neck with it, right?

4. When physician only describes the ROM of the spine and ribs and doesn't mention the pelvis, I don't give credit for the spine,ribs and pelvis. Does anyone have an opinion on that?

I am the only coder in my clinic of 25 physicians, I have worked with other coders in the past, and was able to"bounce" these kinds of questions off
each other, but now I am in a remote area that has very limited coding experience and really don't have anyone to discuss these things with.

Your input is much appreciate.

Stefanie

 

[FTessaBartels]

Yes, No, No, Correct

# 1. YES I count this as either ROS or Past med Hx depending on what I need

# 2. "Alert and oriented X 3" always seems to go together. I would not give additional credit for the word "alert."

#3. 1997 guidelines are pretty specific. If all the physician documents is "HEENT normal" then I do NOT give ANY bullets under 1997 guidelines.

#4. I agree with you. The 1997 guidelines are specific: spine, ribs and pelvis. If you are missing any one of them you don't get credit for that bullet point.

Hope that helps.

F Tessa Bartels, CPC, CEMC