ROS vs Examination Audit

mmunoz21

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Hello,

When auditing E&M when/where do you give credit under "ROS" and or "Examination"? do you give credit on both sides, if a pt's chief complaint is earache, under ROS do you check off ENMT, and also under Examination since the doctor reviewed and examined? this is just 1 scenario..it's a bit confusing....
 

Lisa Bledsoe

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If the chief complaint is earache you would use that in your HPI, not the ROS. You can't use it in both the HPI and ROS unless it is stated again. Otherwise you would be "double-dipping". The doctor must document that he/she actually examined the ear to count in the exam. Does that help?
 

mmunoz21

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Ros/medical Exam

Thanks,

How about if the Dr lists the systems (ie: EENT, Lungs, Heart, Extremities) has notations on them, at this time do you use them for both ROS and Medical examination?
 

Lisa Bledsoe

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The ROS is questions and answers about related systems, so unless your doctor actually examined those systems it cannot be counted in the exam. ROS is Q/A, Exam is hands-on.
 
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