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Review of Systems - type 2 diabetes

  1. #1
    Default Review of Systems - type 2 diabetes
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    I am auditing an office visit for an established patient with 2 chronic/inactive diseases, hypertension and type 2 diabetes. In the history the doctor dictates "Patient is 54-year-old female who presents today for follow-up of hypertension and type 2 diabets. She had labs done on January 7. Overall she is feeling well." There is no separate entry for review of systems. Any suggestions for a review of systems from the above note? Thanks, Nancy Perry, CPC

  2. #2
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    Quote Originally Posted by nperry View Post
    I am auditing an office visit for an established patient with 2 chronic/inactive diseases, hypertension and type 2 diabetes. In the history the doctor dictates "Patient is 54-year-old female who presents today for follow-up of hypertension and type 2 diabets. She had labs done on January 7. Overall she is feeling well." There is no separate entry for review of systems. Any suggestions for a review of systems from the above note? Thanks, Nancy Perry, CPC
    To count as chronic illnesses for the HPI, the status of the conditions must be given. The closest thing you have to that is "Overall she is feeling well". I'd be hesitant to give any credit without something like "HTN well-controlled w/meds", or "Blood sugars have been within normal limits", to supplement the fact that she has the condition, and is feeling okay today. (You've got to establish medical necessity for the visit, and it's just not present in the statement you've got.) And to answer your question, no - there's no discernable ROS there. You shouldn't assign this as anything higher than 99212, if it qualifies for an E/M at all. Hope that helps!

  3. #3
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    Thanks so much for your reply. I appreciate the feedback. That's what I thought but just wanted to be sure. Nancy

  4. #4
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    Hi
    I am dr sunil from mumbai
    you can take one bullet for constitutional area for ROS "Overall she is feeling well"

    dr Sunil
    Mumbai India

  5. #5
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    Quote Originally Posted by drdadhichsunil View Post
    Hi
    I am dr sunil from mumbai
    you can take one bullet for constitutional area for ROS "Overall she is feeling well"

    dr Sunil
    Mumbai India
    Hello, Dr. Sunil!

    Let me put it this way: I wouldn't allow credit for that statement in an audit, because it's too vague, and doesn't pertain to any one particular system. There's simply too much room for interpretation.

    On the other hand, if I were having to defend this to an auditor, I'd probably argue that it could fall under Constitutional, as you've suggested. The difference is in the perspective: Auditors should strive to educate the physician on acceptable documentation techniques; we're not doing anybody any favors by being liberal with the credit we're assigning. Since coding and auditing are so subjective, the best way to ensure compliance, is to prepare for the worst case scenario.

    Practice administrators and appeals specialists have a different interest, though - they are concerned with the bottom line. Appeals specialists should try to fiercely defend their providers' code choices to the best of their abilities, and sometimes that means employing creative interpretation of the guidelines, when necessary.

    Auditors keep it black and white, and appeals specialists are all about shades of grey. I hope that was helpful, and not confusing!

    Have a great day!
    Last edited by btadlock1; 04-09-2011 at 04:11 PM.

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