ROS: see ROS from (other document)

renifejn

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An EP physician is being requested by another Cardiologist to render an opinion regarding treatment of periods of bradycardia.

The ROS states: See Cardiology consultation---Can documentation from that consultation be used for this present one?

Is the ROS from another consultation allowed to be used?

What if it is from another speciality? (i.e. Cardiology stating "see General Med H&P)

Thank you
 

dclark7

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This is from the 1995 and 1997 Documentation Guidelines for E/M "A ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reveiwed 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 physician use a common record. The review and update may be documented by:
1) describing any new ROS and/or PFSH information or notiing htere has been no
change in the information; and
2) noting the date and location of the earlier ROS and PFSH

http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf
above is the link to the 1995 guideline.

Doreen, CPC
 
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Evidence it was actually reviewed

Doreen is right: ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reveiwed and updated the previous information. (emphasis added by FTB)

BUT .. there must be some indication that the material was actually reviewed. Just saying "see Dr A's consult" is not an indication that THIS physician has reviewed that information.

F Tessa Bartels, CPC, CEMC
 
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