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Bullets

  1. #1
    Default Bullets
    Exam Training Packages
    We use the 1997 Guidelines, Can you use a bullet from both the ROS and the PE and get credit ?

  2. #2
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    ROS doesn't count towards exam or vice versa. They are 2 completely different things. ROS is the provider asking what is going on, exam is the provider physically checking what is going on.

    Laura, CPC

  3. #3
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    So if you use Constitutional in the ROS can you count it again for the PE ?

  4. #4
    Default
    I guess a better wording of the question would be, Can you count a bullet more than once ?

    Ex:

    HPI- 66 y/o female with abdominal pain. No fever or weight loss. General apperance is well maintained.

    PE- General: No fever or weight loss. No acute distress.

  5. #5
    Default
    You can review the same system you examine, yes.

    In your example

    HPI- 66 y/o female with abdominal pain. No fever or weight loss (this would be cons ROS). General apperance is well maintained (this would be a cons exam bullet even though it is listed under HPI).

    PE- General: No fever or weight loss (if the vitals are documented you could get the other cons exam bullet here). No acute distress.

    Does that make sense?

    Laura, CPC

  6. Smile
    There are three bullets for constituional exam bullet for my speciality(ENT):
    [*]Measurement of any 3 of the following 7 vital signs:sitting or standing blood pressure,supine blood pressure,pulse rate and regularity,respiration,temperature,height,weight(M ay be measured and
    recorded by ancillary staff)
    [*]General appearance of patient
    [*]Assessment of ability to communicate and quality of voice


    ROS constitutional is if the patient reports weight gain,wieght loss, etc.

    Hope this helps

    Shana CPC, CPC-H
    Last edited by Coder2hear813; 06-18-2009 at 11:56 AM.

  7. #7
    Default
    so can i use it twice if only documented once ? Can i use Con in the HPI for a ROS and use it for PE ? My physician might write

    HPI- 66 y/o female with abdominal pain.

    PE-

    General- No fever or weight loss.

    Could i use one bullet for ROS and one for PE ?

  8. #8
    Default
    If the documentation is only no fever, no weight loss the only thing that could be in my opinion is ROS. If there are also vitals, ie bp 120/80, wt 150, temp 98.6, then that is an exam element.

    Bottom line, one statement can not be counted twice.

    Laura, CPC

  9. #9
    Default
    Quote Originally Posted by katmryn78 View Post
    If the documentation is only no fever, no weight loss the only thing that could be in my opinion is ROS. If there are also vitals, ie bp 120/80, wt 150, temp 98.6, then that is an exam element.

    Bottom line, one statement can not be counted twice.

    Laura, CPC
    So you can't use the no fever or weight loss as a bullet for Cons under the PE for General Apperance ?

  10. #10
    Location
    Milwaukee WI
    Posts
    4,466
    Default Your specific question
    cpccoder2008, You ask: so can i use it twice if only documented once ? Can i use Con in the HPI for a ROS and use it for PE ? My physician might write

    HPI- 66 y/o female with abdominal pain.

    PE-

    General- No fever or weight loss.


    NO ... you cannot use the exact same statement (documented only once) to count for both ROS and exam.

    The physician MAY have documented two statements, one under HPI that patient had no complaint of fever or weight loss (which would count as ROS constitutional), and then the physician may have recorded the temp and weight (if using 95 guidelines, you'd still get a bullet for constitutional ... 97 needs 3 vital signs to get a bullet).

    F Tessa Bartels, CPC, CEMC

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