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Ros or exam

  1. #1
    Question Ros or exam
    Medical Coding Books
    One of our surgeons did this consult and I am confused wether or not it can be counted for the ROS or Exam or both?

    PMH: HTN, Breast Cancer
    PSH: C-Section, Breast lumpectomy
    NKDA
    Meds: Lisinopril/HCTZ
    Social: no tobacco, no ETOH, no drugs
    USS: AFib
    Gen: A+O x3 NAD
    HEENT: NC/AE PERRLA TMI neck supple
    Heart: RRR 5m
    Lungs: CTA b/l
    ABD: soft tender rlq
    EXT: 5 edema
    Neuro: CNII, intack
    CT: + appendicitis

    Plan: Pt will go to er roday with DR. REDD for Lap Appy poss laparotomy

    Any help will be great

  2. Default Response
    That is History and Exam, but no ROS was mentioned. If he had stated at least 3 chronic diseases you could have skipped History and ROS and moved on to the Exam. But that looks like a level I consult.

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default HPI and Chief Complaint?
    Where are the chief complaint and HPI?

    Without those two basic elements, this is not codeable even to a level 1.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Default
    There was a cc. Pain in lower abdomen 2 days ago, got worse at night. Low grade fever. Did not feel like eating.

    Can somebody help me on what key words I should be looking for with ROS?

    Thanks

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default Rules to remember
    First rule to remember .... if you do NOT have 4 elements of HPI you do NOT need to bother with PFSH at all (you can't count PFSH unless you have at least 4 elements of HPI - or status of 3 chronic conditions).

    Second rule - if you DO have 4 elements of HPI (or status of 3 chronic conditions), you need at least 2 systems in ROS BEFORE counting any PFSH.

    Okay you have:
    cc. Pain in lower abdomen 2 days ago, got worse at night. Low grade fever. Did not feel like eating.
    PMH: HTN, Breast Cancer
    PSH: C-Section, Breast lumpectomy
    NKDA
    Meds: Lisinopril/HCTZ
    Social: no tobacco, no ETOH, no drugs


    cc: pain
    HPI: Location - lower abdomen
    Duration - 2 days
    Timing or context - worse at night
    Assoc signs - did not feel like eating

    ROS: Const - low grade fever
    Allergy/immunologic - NKDA

    PFSH: PMH - c-section & breast lumpectomy
    social history - no tobacco, etc

    This gives you a detailed history. If he had included a family history you would have a comprehensive history.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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