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E/M university case of the week

  1. #11
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    My opinion, yes.


    INTERVAL HISTORY: Patient continues to have constant gnawing mid-epigastric abdominal pain which is 8/10 in severity.

    ROS: Positive for intermittent nausea and vomiting. Negative for melena or hematemesis. No chest pain or shortness of breath.


    Mid egipastric abn pain can mask or mimic other underlying issues. In this scenario, it's safe to credit 3 ROS.

  2. #12
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    I agree, thank you for reading my very long post I'm a little rusty on the whole E/M and wasn't quit sure about the ROS.

  3. #13
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    Looks like you're on the right path to me!

  4. #14
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    My guess on why it would say 2 systems reviewed instead of 3, which I agree 3 were done, is because it doesn't make a difference. The levels of history are affected by 0 ROS, 1 ROS, 2-9 ROS, and 10+ ROS.

    I do the same thing myself, I will usually put 2-9 ROS when I audit instead of saying 6 or whatever it maybe. I do this to help reinforce to the providers they get no more credit for reviewing 9 systems than they do if only 2 systems were reviewed. Many times the ROS is what keeps my specialists from getting the comprhensive histories.

    Just my take on it,

    Laura, CPC

  5. #15
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    Quote Originally Posted by cpccoder2008 View Post
    Yes i understand now, after reading all the documents it started to be clearer. But am i right to say that there are 3 systems being reviewed instead of 2 ?
    Yes. And I agree with Laura that perhaps he is only stating 2 because there needs to be 10 to go higher in the ROS. That or it's just a typo on his part.
    Lisa Bledsoe, CPC, CPMA

  6. Default
    I agree with 3 ROS... GI, CV and Resp. I have always counted SOB as respiratory.

  7. #17
    Location
    Salt Lake North
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    Cool
    Yes, you are right. I asked Dr. J and his response was yes, the resp syst was reviewed. You can see it on the web site. Good catch !

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