eagomar
Guest
Hello,
We have a new pulmonologist, who specializes in sleep studies. I've been auditing a couple office visits and consults prior to it getting billed and I'm noticing that when he is documenting his HPI, he tends to state all other 10 point review of systems are negative, but doesn't actually break them down. Is this acceptable?
Here is an example:
Reason(s) for Visit:
1. sleep study follow up - AHI of 0. Primary snoring. significant daytime fatigue. Poor sleep efficiency (40.5%). PLM's 47/hr causing arousals.
Difficulty initiating and maintaining sleep. Severe knee pain and carpal tunnel pain. Very active mind at bedtime. Makes lists at night. No lights. No television. Does not face clock. Only caffeine in morning is a cup of coffee. On Prilosec for GERD. Has post nasal drip at night. When she cannot fall asleep in 30-45 minutes she reads a book (sometimes leaves room and other times stays in bed). Goes to bed at 11:30. Wakes up at 6:30. Wakes up 3 times a night. Has pain when she wakes up.
All other 10 pt review of systems negative.
The doctor then does have a thorough, PFSH, physical exam and assessment plan. My confusion is that the ROS are not broken down at all and just merely stated in the reason for visit. How can I take that into consideration when auditing his consults??
Thanks!
We have a new pulmonologist, who specializes in sleep studies. I've been auditing a couple office visits and consults prior to it getting billed and I'm noticing that when he is documenting his HPI, he tends to state all other 10 point review of systems are negative, but doesn't actually break them down. Is this acceptable?
Here is an example:
Reason(s) for Visit:
1. sleep study follow up - AHI of 0. Primary snoring. significant daytime fatigue. Poor sleep efficiency (40.5%). PLM's 47/hr causing arousals.
Difficulty initiating and maintaining sleep. Severe knee pain and carpal tunnel pain. Very active mind at bedtime. Makes lists at night. No lights. No television. Does not face clock. Only caffeine in morning is a cup of coffee. On Prilosec for GERD. Has post nasal drip at night. When she cannot fall asleep in 30-45 minutes she reads a book (sometimes leaves room and other times stays in bed). Goes to bed at 11:30. Wakes up at 6:30. Wakes up 3 times a night. Has pain when she wakes up.
All other 10 pt review of systems negative.
The doctor then does have a thorough, PFSH, physical exam and assessment plan. My confusion is that the ROS are not broken down at all and just merely stated in the reason for visit. How can I take that into consideration when auditing his consults??
Thanks!