Holland, OH
Best answers
We (the coders) are having a lot of trouble auditing our ROS

Our docs insist on documenting no change from previous visit.

I am not sure what an insurance company would allow

Most of the time the docs do not date what visit they are reffering to and if they do - that visit says no change from previous visit and so on.

Does any one else have this problem and what is acceptable?

Thnaks Heather
Knoxville, TN
Best answers
A provider can refer back to the ROS on another date of service and/or the Past Family Social History-- BUT he MUST take the reader there. For example,
"ALL ROS has been reviewed from the 11-1-2007 encounter and ALL systems remain unchanged."
The KEY is when you are auditing a note, we have to be able to count how many systems to give them credit for so he/she must say how many they reviewed. If then they also tell you where this information is in the chart (and they actually did review it with the patient) then it becomes billable.

I recommend to all of my physician's that they initial and date the entry they are referring to so that we can prove he/she was actually there reviewing the record- that is not a documentation requirment, but is recommended.

So they can refer back, but they must tell me where they are referring to and what they are referring to. If they do this, then anytime an insuranc carrier request that record, the form or other date of service encounter that has the information they referred to MUST be sent with the current note. Otherwise, the documentation is not complete.

Sorry I rambled on and on.....



True Blue
High Point, NC
Best answers
!DG: A ROS and/or a 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. This may occur when a
physician updates his or her own record or in an institutional setting or
group practice where many physicians use a common record. The
review and update may be documented by:
• describing any new ROS and/or PFSH information or noting
there has been no change in the information; and
• noting the date and location of the earlier ROS and/or PFSH.

Page 8 for the 97 guidelines