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"insomnia" in ROS-neurological or psychiatric?

  1. #1
    Question "insomnia" in ROS-neurological or psychiatric?
    Medical Coding Books
    Where is it actually documented where to place "occasional insomnia" in the review of systems? Some texts say neurological and some texts say psychiatric for sleeping habits.

  2. #2
    Location
    Louisville, KY
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    I thought that it was constitutional.

    What sources are you using?

  3. #3
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    Under Constitutional, it states "sleep habits" and under Psychiatric, it states "sleep disturbances". So, I think I would put it under Constitutional.
    Hope this helps.
    Kathy

  4. #4
    Location
    Greeley, Colorado
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    I agree with Kevin and Kathy...

  5. #5
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    Thanks for the responses, but now I'm even more confused. The manual I'm learning from for E/M is Medical Record Auditor. The only place it states to place any sleeping habits for ROS is under Psychiatric. The instructor said to put it under Neurological. And you all agree to put it under Constitutional? Can you please tell me where that is stated? Is it in the guidelines? Thanks a bunch!

  6. #6
    Location
    Louisville, KY
    Posts
    1,101
    Default
    Not to add to the confusion, but since insomnia is a sleep disturbance (just like nightmares, frequent awakening, etc), it could be "ticked" under Psychiatric as well.

    If you haven't already, you're now discovering that with Auditing E/M items mentioned/documented may fit into more than one category. Just as long as you're using it in one and only one you have no worries.

    For instance, if you already have constitutional marked for "no wt. loss", then you could score "insomnia" under the Psych and move your ROS to Detailed.

    Just a thought/clarification.

  7. #7
    Lightbulb stick with it buddy
    Although Kathy and Kevin are technically correct. I would cleave to what you instructor says; just to avoid ambiguity. E/M codes vary extensively to facility mythology and most likely your instructor is training you for a particular facility mythology aimed at a medical record auditor position. If you believe your instructor is hypothetically checking off elements, then you’re just going to be required to remember specific scenarios why you would code a level 2, 4, 1, 5, 3. That is the challenge of E/M which distinguishes a good coder to an advanced auditor. Of course you must not forget the science element.
    Last edited by 007CPC; 02-14-2008 at 03:45 PM.

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