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Unattainable ROS

  1. #1
    Default Unattainable ROS
    Medical Coding Books
    Can anyone tell me what level to assign for ROS when the patient is unable to provide the information? i.e. problem pertinent, extended, or complete? Thank you for the help.

  2. #2
    Location
    Greeley, Colorado
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    You can get a complete ROS if your provider documents that the patient was unable to provide it and why.
    Lisa Bledsoe, CPC, CPMA

  3. #3
    Default Thank you
    Thanks a lot, that really helped.

  4. #4
    Default ER
    We had a patient come through the ER with an overdose, doctors put "unable to get a complete ROS due to patient being sedated and intubated from overdose " I gave a complete ros for this, Is that correct ?

  5. #5
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    Greeley, Colorado
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    Quote Originally Posted by cpccoder2008 View Post
    We had a patient come through the ER with an overdose, doctors put "unable to get a complete ROS due to patient being sedated and intubated from overdose " I gave a complete ros for this, Is that correct ?
    Absolutely! As long as it is documented as to why the ROS could not be obtained.
    Lisa Bledsoe, CPC, CPMA

  6. #6
    Default Depends on the carrier
    WPSMedicare will not allow this. You only get credit for what you actually document, regardless of the reason why you couldn't get it.

    Remember ROS doesn't have to come from the patient, if there is another history source (ie family) you can get the history from them.

    Laura, CPC, CPMA, CEMC

  7. #7
    Location
    Overland Park, KS
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    1,166
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    The E/M guidelines do not state that the provider gets credit for a comprehensive history if they are unable to obtain a history from the patient. The guidelines just say that the provider has to state why he/she can't obtain the history. What happens beyond that point falls to the carrier. I would recommend in this case you consult with your carrier to see what their recommendation is.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

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