ROS- Unobtainable???

Cpolisena

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What to do when an H&P, Consult, ER note etc. have the 'Review of Systems' documented as 'Unobtainable'?

I've read mixed opinions from other coders & CMS publications. I am not one single bit sure I have an answer that I feel comfortable with. Especially when the ROS is what my code of choice is going to rely on since the rest of the note is documented properly. So we could be talking about selecting a 99223 or a 99221 for an admit or even a 99255 or 99252 for IP Consult, again, depending on the definition of a 'Unobtainable' ROS. That's a lot of $ riding on the choice of codes!

I've read both the 1995 & 1997 CMS E-M Documentation Guidelines and nothing is clear cut! Which I should have probably expected in the world of coding :)

Can anyone help with something more substantial to stand on, a document or something in writing would be awesome!

Thank you :confused:
 

btadlock1

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ROS can be taken by the physician, or ancillary staff, or even by the patient completing a questionnaire, as long as the physician references it in the note. Documentation guidelines state "The chief complaint ROS and PFSH may be listed as separate items of history, or they may be included in the description of HPI. An ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information..."

Also, there's the rule that says "If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition which precludes obtaining a history."

So the question I have is, how much HPI do you have? Could some of it be credited to ROS instead?

One last thing - You'd only use an IP consult code if the doctor is not the admitting physician.
 

LLovett

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Depends on where you are and who you are billing...

We base all our decisions on what our Medicare carrier says unless the particular carrier we are dealing with has a written policy that directs us differently. Having said that I am in Michigan and WPS is our Medicare carrier. They have a lot of great info on E/M coding, below is a link and some pertinent info based on your question.

http://www.wpsmedicare.com/part_b/education/evalmngmntqahistory.shtml

Q 2. Where does it state that if the history is unobtainable you cannot automatically bill a comprehensive history? Do you automatically have to bill based on a problem-focused history?
A 2. There is nothing notated in the 1995 or 1997 DG to indicate any level of history is automatic. The physician should document the reason the patient is unable to provide history and document his/her efforts to obtain history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information contained therein to document some of the history components (past medical, family, social).

Q 3. We are unable to obtain history as the patient is intubated. Do we have to bill a Not Otherwise Classified (NOC) code?
A 3. You would only submit a NOC code when you are unable to document any of the history elements. If you are talking to the patient's family or others to obtain history, document the work performed and code based on the work performed.


Hope this helps,

Laura, CPC, CPMA, CEMC
 

btadlock1

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We base all our decisions on what our Medicare carrier says unless the particular carrier we are dealing with has a written policy that directs us differently. Having said that I am in Michigan and WPS is our Medicare carrier. They have a lot of great info on E/M coding, below is a link and some pertinent info based on your question.

http://www.wpsmedicare.com/part_b/education/evalmngmntqahistory.shtml

Q 2. Where does it state that if the history is unobtainable you cannot automatically bill a comprehensive history? Do you automatically have to bill based on a problem-focused history?
A 2. There is nothing notated in the 1995 or 1997 DG to indicate any level of history is automatic. The physician should document the reason the patient is unable to provide history and document his/her efforts to obtain history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information contained therein to document some of the history components (past medical, family, social).

Q 3. We are unable to obtain history as the patient is intubated. Do we have to bill a Not Otherwise Classified (NOC) code?
A 3. You would only submit a NOC code when you are unable to document any of the history elements. If you are talking to the patient's family or others to obtain history, document the work performed and code based on the work performed.


Hope this helps,

Laura, CPC, CPMA, CEMC

I think I can see where the question of the history level is coming from - the guidelines for selecting the history level say that all 4 areas (CC, HPI, ROS, PFSH), must be met or exceeded to qualify for a particular level, so without any ROS, how could the history be comprehensive? How would you work around that part if there's no family to ask, particularly for a new patient?
 

Cpolisena

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I think I can see where the question of the history level is coming from - the guidelines for selecting the history level say that all 4 areas (CC, HPI, ROS, PFSH), must be met or exceeded to qualify for a particular level, so without any ROS, how could the history be comprehensive? How would you work around that part if there's no family to ask, particularly for a new patient?
Part of your response, "so without any ROS, how could the history be comprehensive? How would you work around that part if there's no family to ask, particularly for a new patient?" is my main dilemma in this case. The ROS simply says, "Unobtainable" with no reason given as to why. I've had similar notes in the past but they at least gave some explanation somewhere in the note as to why the patient couldn't respond to questions. So I guess my basic question could be, without any ROS period, is the ROS simply 'problem focused' in terms of how to select the appropriate level if I can't pull any ROS bullets out of any other part of the note, regardless if it's a H&P, Consult etc?

I'm not trying to make this a difficult question, but I'm dealing with our most difficult Dr. who thinks everything is the highest level even if chest pain is all he has, I work for a cardiology clinic! He'll be one to want something in writing, otherwise it's my opinion versus his, and of course, he's never wrong :)

I really appreciate your help so far too!! Don't want to leave that unmentioned :)
 

btadlock1

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CMS guidelines clearly state that if the history is unobtainable, the reason must be clearly documented (eg, patient intubated, in a coma, etc.). But that still brings me back to my first question - how do you have HPI if the ROS is unobtainable? Isn't the HPI derived directly from answers given by the patient in most cases? It just doesn't make sense to me that they would be able to obtain any history, if they're incapable of obtaining all of it.
 

RebeccaWoodward*

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Our soon to be MAC carrier provides some guidance on this...

Question:
Would 'credit' be given under the review of systems (ROS), and past, family and social history (PFSH) if a provider is unable to continue the service because the patient becomes agitated/combative and will not allow the provider to continue?

Answer:
Yes. If the provider is unable to obtain a history from the patient or other source (no family, significant other or medical records available), the record should describe the patient's condition or other circumstance that precludes obtaining a history. There must be a clear picture that reflects why the provider was unable to obtain this information.

http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Ohio Part B Carrier~Browse by Topic~Frequently Asked Questions~EM~89JE7N2226?open&navmenu=||
 

Cpolisena

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The only reason there is any bit of an HPI is because the patient was transferred from another hospital since we're one of the top heart hospitals in SC. I don't have the note in front of me but I do know the info dictated by my Dr. came from whatever note the EMS driver brought from the other hospital. This is one of the odd cases that the patient info was soooo minimal.

I oddly had similar note this morning but enough was included in the HPI to give me something to stand on for the ROS portion!
 

btadlock1

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Now, that makes sense. Is it possible for you to have the doctor append the record to clarify that the patient couldn't speak, and only the EMS driver could provide minimal history? If so, then I think you'd have enough to justify skipping ROS.
 

Cpolisena

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That could work, he loves having to ammend his work! On a funny kind of note, his wife is his NP and she does most of his dictations! Let's just say they're my favorites to work with especially corrections ;)

Thanks again- Chris
 
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