Question ROS

Pathos

True Blue
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650
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Beaverton OR
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You are writing that the provider states "ROS as noted in the HPI". You can use elements in the HPI towards the ROS, as long as you are not "double dipping"; meaning you are not using elements that has already been counted towards another part of the E/M visit.

Hope that helps!
 

Pathos

True Blue
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650
Location
Beaverton OR
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1
The components that determine any E/M visit are split up into: History, Exam and Medical Decision Making. The History component are further split up in CC, HPI, ROS and PFSH. If any of those four History components are missing, then you cannot extract a full History from that documentation, and in extension the visit as well.

However, with an Established visit, you only need 2 of the 3 E/M components (Hx, Ex or MDM), which means you can still choose the E/M level based on the Exam and MDM of that documentation visit.
Even with the ROS, you are not sharing enough information for me to make an educated guess towards any E/M level, based on the information given here.

References:
CMS E/M guidelines
 

MAWK

Networker
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Montezuma Creek, UT
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thank you I could never get a gripe of how to determine the E/M visits. I have attended workshops but was always confused but your explanation is wonderful.
 

anthia

New
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Similar question. I have a provider who did a great job on the HPI for a NEW patient with a full history with complete symptoms but the ROS only states "ROS as noted in the HPI". Is the ROS statement enough to upgrade this visit from a 99201? Can I use some of the HPI, without double-dipping for the ROS?
 

ccollison

Networker
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Bay City, Michigan
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You can use items from the HPI towards the ROS as long as you are not double dipping. Often with a large HPI, there is something that pertains to the ROS and really belongs in the ROS. They just like to use run on sentences!!

C Collison
 
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