ROS with 1995 E/M guidelines

wsue50

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Using the 1995 guidelines, how many systems are documented in the following statement: "Patient is AO x 3 with no focal deficits.” I am not sure if it is one or maybe two.
 

btadlock1

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The guidelines for ROS are the same for both:
A ROS is an inventory of body systems obtained through a series of questions seeking to identify
signs and/or symptoms which the patient may be experiencing or has experienced.
For purposes of ROS, the following systems are recognized:
• Constitutional symptoms (e.g., fever, weight loss)
• Eyes
• Ears, Nose, Mouth, Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunologic

I would consider that statement Neurological and Psychiatric; psych for the 'alert and oriented', and neuro for the 'no focal deficits'.
 
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I'm confused. If the MD is stating that the patient is AO x 3 and no focal deficits, this is actually part of the exam, not the ROS. It would be neurological under the examination.
 

btadlock1

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Hvizdash is right - that would actually be an exam statement, since it's and abservation from the physician, and not a positive or negative response from the patient. I still think that psychiatric should be given credit for th AOx3 portion of the statement, and would love clarification on when it would be appropriate to do so, though.
 
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It seems like exam to me

THe phrase seems like exam to me and it would count as psych (for A&Ox3) and neuro (no focal deficits).

You cannot use the physician's observations (i.e. exam findings) as ROS.

If the physician documented "Patient has experienced fugue states in the past, but today is A&Ox3" then I would count the "fugue states" comment as neuro (or psych) ROS, and the A&Ox3 as psych exam.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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