Wiki ROS question (Constitutional)

[CoderinJax]

Hi!
Curious as to other coders thoughts.

If you review an E&M record and it states: "patient underwent a joint injection in the right elbow during the last visit. He is doing well. He is undergoing a home exercise program and is here today for a RX refill", would you consider the statement "he is doing well" as ROS-General/Constitutional credit?

The record doesn't elaborate any further than what is documented above, so I want input from others if you'd give the ROS credit for any of the above. (OR do you see ANY other ROS for that matter)

Thanks so much!

 

[AdamlShoop]

I certainly don't have years of experience in E/M, but as I am studying for the CEMC now, I would say that I would NOT count that towards a constitutional element. Good luck!

 

[MARY K]

code for busy orthopedic practice, and no we would not use that as constitution, but as part of HPI-F/U injection, pt doing well.

 

[Pathos]

code for busy orthopedic practice, and no we would not use that as constitution, but as part of HPI-F/U injection, pt doing well.

I agree with the statement above. ROS - Constitutional is generally reserved for conditions that effect the whole body, like :Fevers, chills, weight change (loss/gain), trouble sleeping, etc. "Doing well" would probably be more appropriate in the HPI section.

 

[NiteshlalKoyalkar]

Hi,
No, "doing well" does not qualify for the Constitutional/general ROS .

 

[CoderinJax]

Thank you all!

I appreciate all of the input; It helps me greatly!