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ROS: see ROS from (other document)

  1. Default ROS: see ROS from (other document)
    Medical Coding Books
    An EP physician is being requested by another Cardiologist to render an opinion regarding treatment of periods of bradycardia.

    The ROS states: See Cardiology consultation---Can documentation from that consultation be used for this present one?

    Is the ROS from another consultation allowed to be used?

    What if it is from another speciality? (i.e. Cardiology stating "see General Med H&P)

    Thank you

  2. Default
    Can anyone help with this?

    thanks

  3. #3
    Location
    Hartford, CT
    Posts
    723
    Default
    This is from the 1995 and 1997 Documentation Guidelines for E/M "A ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reveiwed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physician use a common record. The review and update may be documented by:
    1) describing any new ROS and/or PFSH information or notiing htere has been no
    change in the information; and
    2) noting the date and location of the earlier ROS and PFSH

    http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf
    above is the link to the 1995 guideline.

    Doreen, CPC

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default Evidence it was actually reviewed
    Doreen is right: ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reveiwed and updated the previous information. (emphasis added by FTB)

    BUT .. there must be some indication that the material was actually reviewed. Just saying "see Dr A's consult" is not an indication that THIS physician has reviewed that information.

    F Tessa Bartels, CPC, CEMC

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