Results 1 to 5 of 5

Is this just a rule of thumb??????

  1. #1
    Default Is this just a rule of thumb??????
    New Call-to-action
    I am trying to get some assistance in finding some documentation that clarifies that the ROS or HX information must be dictated prior to the Examination and MDM section of a visit. I have been researching all day with no luck. Can you please assist me? I am doing a rather large audit and need supporting documentation for this issue. Thank you!

  2. #2
    If the physician(s) you are reviewing are following a SOAP note format then yes, the CC, HPI, ROS and PFSH (these are the "S", subjective, portion of the SOAP note) needs to be documented before the exam and MDM. If you are reaching for ROS and/or HPI in the "AP", assessment and plan or MDM, then there is a problem with the formatting and flow of the information being documented.

    You should suggest that they stick with the SOAP note format for consistency. That should also be part of the billing compliance plan for the office as to the formatting of documentation.

    Good Luck!
    Jill Tom, COC, CPC, CPMA, CPC-I
    East Valley Kachina Coders
    East Valley Mesa, AZ AAPC Local Chapter
    President 2011
    President-Elect 2010
    New Member Development Officer 2009

  3. #3
    Okay thank you.. My only question is if they have the ROS after Examination can I still count that towards ROS or would that be invalid? Meaning if they have extended HPI, complete PFSH and allergies ONLY after HPI but the list of systems at the end of the note then that would make the visit expanded problem since I couldn't count the rest of the ROS information.

  4. #4
    Milwaukee WI
    Default No rule
    There is no rule that any of the elements have to be recorded in any order at all. Though it certainly makes it easier on the auditor to have it done "in order" - CC, HPI, ROS, PFSH, Exam, A/P. You take the elements whereever you find them (just make sure you aren't double dipping ... i.e. counting the same phrase twice)

    The actual SOAP format is not really very helpful either as many forget elements of HPI, ROS, PFSH using it. (Dr Jensen on recommends AGAINST the SOAP format.)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. #5
    Okay.. Thank you.

Similar Threads

  1. thumb fracture
    By Jamie Dezenzo in forum Orthopaedics
    Replies: 0
    Last Post: 09-28-2012, 07:49 AM
  2. Trapeziectomy Thumb
    By cwilson3333 in forum Orthopaedics
    Replies: 0
    Last Post: 02-23-2012, 08:44 AM
  3. thumb coding
    By Rajebpt in forum Interventional Radiology
    Replies: 0
    Last Post: 10-17-2011, 06:29 AM
  4. Thumb injury
    By richelle25 in forum Orthopaedics
    Replies: 1
    Last Post: 06-14-2011, 05:57 PM
  5. Gamekeeper's thumb
    By cpccoder2008 in forum Diagnosis Coding
    Replies: 1
    Last Post: 10-22-2010, 10:33 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.