Wiki Ros

[bertll]

When the MD states ROS: Not otherwise obtainable, but the HPI states Unable to provide any history, mostly just saying thank you, but not answering questions in any meaningful way so the histiry is obtained from the ER staff and notes in old record as her niece had left by the time I got to the ER, does this count for a complete ROS?:

 

[martinni1974]

The intent of being credited a complete ROS when history in unobtainable is supposed to be becausee the patient's cognitive status is impaired, the pt is unconscious etc, and the history is not able to be obtained from any other source. When documented as such, upon audit, certain MAC's & payers will credit you a complete ROS. Not all MAC's/payers follow this guideline. This is not an AMA/CPT rule and can vary from payer to payer.

The documentation you quoted is weak but still leaning toward the correct intent.

I would give Dr a few pointers on cleaning it up some and making sure he understands the intent of that rule and knows the correct "buzz" words for those clinical scenarios.

Good Luck!