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  1. #1
    St Louis West Missouri Chapter
    Question Ros?
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    Tell me your thoughts on this ROS:

    REVIEW OF SYSTEMS: Not really possible to obtain given the patient's current aphasia.

    Does this count as 1 element? (1995)


  2. Default
    He gets credit for a Complete ROS. He has documented he is unable to obtain and why he is unable to obtain. Both must be documented to get credit

  3. #3
    St Louis West Missouri Chapter
    Thank you!
    Is there anywhere I can find this in print, so I can show my doctor?

    Thanks again,

  4. #4
    North Carolina
    DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.

    Q 2. Where does it state that if the history is unobtainable you cannot automatically bill a comprehensive history? Do you automatically have to bill based on a problem-focused history?

    A 2. There is nothing notated in the 1995 or 1997 DG to indicate any level of history is automatic. The physician should document the reason the patient is unable to provide history and document his/her efforts to obtain history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information contained therein to document some of the history components (past medical, family, social).

    Be certain that your carrier will allow a comprehensive history in the event the provider can not obtain this information. Some carriers have stricter guidelines than others. All efforts should be exhausted by the provider and documented thoroughly.
    Rebecca CPC, CPMA, CEMC

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  5. #5
    St Louis West Missouri Chapter
    You guys are the best. Thanks!


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