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Please need help auditing on ros

  1. Default Please need help auditing on ros
    Medical Coding Books
    I POSTED THIS HERE FIRST BEFORE I REALIZED THERE WAS AN AUDITING TAB!!



    I AM DOING AN AUDIT ON AN H&P. INPT HOSPITAL. THE ROS HAS THREW ME OFF BECAUSE OF PTS CONDITION. DOES DR NOT GET ANY MORE CREDIT THAN EXTENDED ROS ON THIS?

    HPI: the pt is noverbal, on the ventilator, therefore, most of the information was obtained from teh chart, from the transfer record, and the staff

    hpi: the pt is a 60 yr old white male with a hx of copd, emphysema, pulmonary htn, obstruct sleep apnea, and chf, who was found down on a week ago oby family members for an unkonwn period. the pt was transferred to another hospital in critical condition. the pt was intubated and had a pretty complicated hsopital stay there, including questionalbe gi bleed and sepsis with pneumonia. the pt has been followed by infectious disease, by pulmonary, and by gastroenterology too. the pt ended up having a tracheostomy placed second to difficulty weaning her off the ventilator. she also ended up having a peg tube placed on admit day prior to transfer. the pt was also seen by neurology there for toxic metabolic encephalopathy. when she was seen by infectious disease, the pt was treated with zosyn and vancomycin at some point, and was switched flagyl for questionalbe c diff, athough that was not confirmed by testing.

    ros: ros is very limited secondary to the patients condition, but there is no reported nausea or vomiting. positive for diarrhea.



    I added the hpi because I was wondering if that could be used also on the ros. What should a dr do when a pt is in a coma like this with documentation. Please help, I need some good advice on auditing this. A extended ros is not fair.
    Last edited by sherryjean27; 08-21-2009 at 10:52 AM.

  2. #2
    Default
    I guess the first question I have is what does the exam look like? If it is not comphrensive it doesn't matter what the history level is you are stuck at a 99221.

    Laura, CPC, CEMC

  3. Default
    Thanks for your quick reply, exam is comprehensive

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default I'd give full credit
    While he didn't state specifically in the "ROS" section that he could not obtain full info due to patient's ventilator status, he did include the unusual circumstances under HPI. I'd give full credit for a complete ROS, given the patient's inability to respond.

    Hope that helps

    F Tessa Bartels, CPC, CEMC

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