I concur with everything that Laura, Debra, et al have written about this.

Your physician is leaving a LOT of money on the table by not having a patient questionaire that the patient completes while waiting for her appointment. The complete ROS can be listed there and the physician only would have to review, sign, date and refer to it in his/her note.

You mention that this is a consultation referred for a second opinion. Okay ... you need to meet 3 of 3 elements for a consult - history, exam, MDM.

You mention that you have "allergies" noted ... you can use that as one element of ROS ... so you have at least a 99242. If you can find one more element of ROS somewhere in the history section of your note then you have a 99243. You would need to have 10+ systems ROS to get to a 99244.

If you can post a note it would be easier for us to help you identify what is what. Debra is absolutely correct that history & ROS are as reported by the patient while the exam is what is personally observed and recorded by the physician. But some physicians mix up their dictations and might say something in the middle of the exam like "she hasn't noticed any lumps, swelling or redness." That little phrase would be a report of what the patient reported NOT what the physician observed, and could therefore be counted in either HPI or ROS.

Hope that helps.

F Tessa Bartels, CPC, CEMC