Results 1 to 5 of 5

Aduting with 1995 guidelines

  1. #1
    Unhappy Aduting with 1995 guidelines
    New Call-to-action
    I frequently use the 1997 guidelines, but am now finding some of our specialists may benefit using the 1995 guidelines. I find them to be more confusing and I am struggling. I would appreciate any feedback on the following exam audited using 1995 guidelines.

    PHYSICAL EXAMINATION: When he came to the emergency room documented heart rate of 77. The patient was saturating at 87% to 91% on 2 liters nasal cannula. His blood pressure was 139/65. His telemetry strip read basically atrial flutter but a 2:1 or 3:1 block with diffuse P wave inversion which is secondary to the atrial flutter pattern. The patient's temperature was also 101.3. He was lying in bed comfortably. He was alert. He was not oriented to place.
    CARDIAC EXAM: Showed regular rate and rhythm. S1, S2 were heard. Heart sounds were
    distant. No obvious murmurs, rubs or gallops were noted.
    LUNGS: Examination of the lungs posteriorly revealed bibasilar rales. The upper lung zones were clear to auscultation posteriorly.
    ABDOMEN: Soft. Non-tender. Non-distended. Positive bowel sounds throughout. No rebound, rigidity, or guarding were noted.
    EXTREMITIES: The lower extremities revealed +2 pitting edema.

    One additional question: The physician states for ROS: unobtainable as patient does not give a proper history. So, he has nothing for ROS--correct?

    Thanks for the assistance.

  2. #2
    One additional question: The physician states for ROS: unobtainable as patient does not give a proper history. So, he has nothing for ROS--correct?
    I don't think 95 or 97 makes a difference in the ROS.

    If the physician documents the patients medical condition that makes it impossible to obtain or documents the attempts / problems encoutered when trying to get the ROS, they can take the complete. I don't think what you have is enough to do that. So if that is all the info you have, I would say this was nothing for ROS.

  3. #3
    The additional details of the note-regarding the ROS Unobtainable are as follows:

    Unable to give proper history when I asked him if he has had any fever. He says "no" and he essentially say "no" for every question that I ask him. He has advances ALZ/Dementia and does not know he is in the hospital.

  4. Default Caveat
    The additional note documenting the advanced dementia should be enough to apply the acuity caveat to the ROS. But it woukld help if the physician stated that due to dementia/alz. history could not be obtained.


  5. #5
    Medical Billing
    Thanks for the information!

Similar Threads

  1. 1995 E/M Guidelines
    By dcraven in forum Auditing General Discussion
    Replies: 1
    Last Post: 05-05-2014, 01:38 PM
  2. 1995 guidelines
    By drsunitha in forum E/M
    Replies: 2
    Last Post: 11-21-2011, 09:06 AM
  3. 1995 Guidelines
    By livininthegray in forum Auditing General Discussion
    Replies: 2
    Last Post: 11-04-2009, 06:55 PM
  4. using the 1995 guidelines.
    By daniel in forum E/M
    Replies: 3
    Last Post: 04-30-2008, 09:25 PM
  5. only use the 1995 guidelines
    By daniel in forum E/M
    Replies: 1
    Last Post: 04-28-2008, 07:44 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.