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EM audit question for Ortho

  1. #1
    Location
    Modesto, CA; Central Valley Chapter
    Posts
    225
    Red face EM audit question for Ortho
    Medical Coding Books
    Hi,

    In the HPI; if it is stated 'x-rays were unremarkable' can this be used as quality or severity?

    TIA!

    Tina

  2. #2
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    It is neither. It would fall under amount/complexity of data for MDM. The physician is actually reviewing the xray, not obtaining history.

  3. #3
    Location
    Modesto, CA; Central Valley Chapter
    Posts
    225
    Default
    Thanks Lisa, that's what I was afraid of...he actuatlly documented it in the HPI and under imaging studies.

    I would like to ask another question.....

    In the HPI states 'parents do not note any specific problems' and then under ROS states 'unobtainable'. From what I understand, because he did not state why it was unobtainable it cannot be used for ROS. However, if he were to document under ROS - Complete ROS reviewed with parents who do not note any specific problems', would we be able to use this as a complete ROS?

    Sorry for the silly questions but it has been a while since I have done ortho audits.

    TIA?
    Tina

  4. #4
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Tina - if the parents are with the child, then a review of systems isn't really unobtainable, as it can be obtained from the parents, just as the HPI and PFSH can be obtained from the parents. As you know, a ROS is a Q/A with the patient - in this case the parents. The unobtainable situation would only be applicable in ED coding as a caveat. I would recommend that the provider note specific ROS rather than the blanket statement. So I guess my opinion is that I would not count this as a complete ROS unless some of the systems are documented with pertinent positives/negatives AND "all other systems are reviewed with the parents and are negative". The other issue is that I have heard that carriers are moving towards not counting the blanket statement "all others..." as complete in their audits. Perhaps someone else can confirm or refute this?? I think this is going to be an area of controversy for awhile...
    Lisa

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