Wiki Unable to obtain ROS

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abill_423

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When a physician dictates that "he is unable to obtain a ROS because the patient is on a ventilator", are you able to count that as a complete ROS? Or would that not count as anything? I think I have read somewhere that you can count this as a complete ROS but can't find that information.

Also, I am interested in hearing from other coders. My job has always primarily consisted of providing additional diagnosis codes when lab tests or procedures that were ordered didn't have diagnosis codes that met medical necessity. Now I have been offered an opportunity to do chart audits for our practice to check the accuracy of our E & M coding. I have been reading the 1995 and 1997 guidelines and have also listened to the basic E & M course on www.emuniveristy.com to try to prepare myself. I am curious how other coders got their start in chart auditing and if you could recommend some good study material to me.

Thanks.
 
No. ROS is a verbal communication between the patient and the nurse, doctor. When the patient is on a ventilator, we cannot take any ROS. But, when a family member by his/her side could give us the necessary details about his health, we can about it in our chart progress note.
 
I was taught that if the provider was unable to obtain a review of systems, as long as he documented the reason then I am able to count it as a full review of systems. This happens quite often for me, as I work for trauma. We often have patients come to the hospital unconscious.
 
I agree with Treetoad... if you're unable to obtain ROS... you have to document why and give an effort to obtain it from some source... I do work for trauma as well, this happens quite frequently.
 
Yes, complete ROS

Yes, you can count it as a complete ROS as long as the reason for not being able to obtain it is given (in this case, patient intubated).
This will also hold true for PMFSH; again, you state why the information cannot be obtained.

Interestingly enough, the "E/M visit of the week" on E/M University had exactly this scenario this week. It was counted as full ROS.

Before you finish coding the visit, be sure that the physician isn't providing critical care (for which s/he must document time spent, and the nature of the critical care). In that case the critical nature of the patient's condition, the nature of the care provided, and the time spent determine the code to use, not the usual Hx, PE, MDM bullet points.

F Tessa Bartels, CPC, CPC-E/M
 
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