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Need help auditing this chart ROS?

  1. Default Need help auditing this chart ROS?
    Medical Coding Books
    i posted this question in e&m also


    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 10:38 AM. Reason: changed complete to extended at the end

  2. #2
    Default Complete
    Why isn't a complete fair? The patient is nonverbal and on a ventilator. The ROS is pulled from the HPI, expanding on the present illness by positive and negative responses. The provider documented the patient's state and why he couldn't obtain any additional information from the patient but did from the records and staff. You can only do what you can. The effort by the provider was there to obtain the information. I would give him a complete.

  3. Default
    thank you for your response. I messed up on the complete part at the end. I meant to write extended. So this is a complete ROS? That sounds great to me!! Thank you for sharing your knowledge with me
    I just don't understand how it can be counted as a complete. I know you are much more knowledgable than me on this, can you tell me how it is complete. I appreciate your feedback so much because I thought I could only get an extended ROS.
    Last edited by sherryjean27; 08-21-2009 at 10:49 AM.

  4. Default
    When history is unobtainable due to the patient's condition, you can count the history as if it was comprehensive. The documentation should make it clear though why history could not be obtained. For example, if the physician said that the "history was unobtainable because the patient was intubated and sedated" I would count this as a comp history.

    Due to the fact that your physician documented that this patient is on a ventilator, we know that he could not have spoken with the patient.

    Lisi, CPC

  5. Default
    Thank you so much, I will note that in my book. Is that only for the H & P or is that for consult too?
    Last edited by sherryjean27; 08-22-2009 at 07:18 AM.

  6. #6
    Default Be careful on this one...
    Check with your carrier before you make this your guideline.

    WPSMedicare does not allow this as a complete history.

    Laura, CPC, CEMC

  7. Default
    I don't really "count" it as a comprehensive history, what we do is just cross history off altogether and level our visit based off of just the exam and MDM, regardless of whether the visit requires 3 out of 3 key elements (ie: an initial visit or consult).

    So, if history is unobtainable (and the provider has documented why it is unobtainable) and
    - the exam is comprehensive
    - the MDM is of moderate complexity

    I would bill this as a 99222.

    Hope this makes sense. I'm confident that coding it this way is correct. Medicare cannot expect physicians to bill lower levels simply because the patient is unconscious (in fact, in those cases, its even more likely that the patient is quite ill requiring a comp exam and MDM of high complexity). Let me add that we only do this if history is unobtainable due to the patient's medical condition. If, for example, the patient speaks another language and we don't have a translator, we can NOT count that as an unobtainable history.

    Lisi, CPC

  8. #8
    Default Again, check with your carrier
    WPSMedicare was very clear, they do expect you to drop your level if you can't meet the history requirements no matter the reason.

    Laura, CPC, CEMC

  9. Default
    I want to thank you bunches for your answers!!

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