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ENT -- ROS and Exam

  1. #1
    Phoenix, AZ
    Default ENT -- ROS and Exam
    Medical Coding Books
    Hi there,

    I need some help, please. From an auditing standpoint, if the ROS states ENT= ears normal, would you count this as 1 for ENT? Or does documentation need to say something differently?

    Also the same for the MDs exam. Does the ENT exam need to state that ears normal, nares and throat and oral mucosa are normal.

    I was taught that the MD should state each one is normal but my new docs are saying no. They say if why do we need to break it down if we are looking at each one and documenting ENT normal.

    Please help.
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

  2. #2
    My understanding is that you only have to review or exam one item for it to count, but if you review or exam all of them, it still only counts one 1.

  3. #3
    Northeast Kansas (NEKAAPC)
    Are your providers using 95 or 97 guidelines? That will make a difference.
    Brenda Edwards, CPC, CDEO, CPB, CPMA, CPC-I, CEMC, CRC
    AAPC Fellow
    AAPC ICD-10-CM/PCS Training Expert

    Kindness is contagious-PASS IT ON!

  4. Default
    You can count it in the Review of Systems as long as the provider addresses either the Ears, Nose or throat.

    The exam is different depending on the guidelines you are using. If you follow the 95 guidelines then you can give credit to the entire system. However, if you're using the 97 guidelines the ears would be considered one bullet.

  5. #5
    Phoenix, AZ
    Thanks for your help. We are using 95 guidelines.
    Last edited by Cyndi113; 06-16-2010 at 12:55 PM. Reason: misspelled word
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

  6. #6
    Spokane, WA
    As far as ROS goes, you only need one statement to count that system.
    If you are using the 95 guidelines, again, only one statement is needed, i.e. Nose clear. You get credit for examining that organ system. When the provider starts giving you more details about each of the elements in that organ system/ body area - it becomes an extended exam/ detailed exam of that system/ area.

    hope that helps a little.
    Last edited by ttate; 07-12-2010 at 02:27 PM.

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