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Chart Auditing - ROS

  1. #1
    Location
    Chicopee, Massachusetts
    Posts
    26
    Default Chart Auditing - ROS
    Medical Coding Books
    I have recently completed an audit of some E/M codes and the group has a ROS, PFSH form. The patient and physician are most often times signing it but they are leaving it blank. Would you take that as having completed the review?

  2. #2
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Not if it is blank. There has to be something documented to cout. A signature on a blank form doesn't cut it for me.

  3. #3
    Location
    North Carolina
    Posts
    3,126
    Default
    I agree with you, Lisa. It's hard to give credit for blanks. I know there are times when it's difficult to obtain this information (dementia, unconsciousness) but in normal circumstances, I feel an effort needs to be made. PFSH and ROS aid in the building blocks of the level of the e/m.

    The ROS obtained on a previous visit does not have to be re-recorded, but all new information must be documented along with a notation stating where the previous information is located in the chart. Also, a review of the PSFH obtained during a previous visit does not have to be re-recorded but, again, new information must be listed along with a notation regarding the location of the previous PFSH.

    Some type of documentation is needed to record pertinent facts, findings and observations about a patient. The physician will be held accountable for his documentation and as stringent as carriers are becoming, it's in his/her best interest to supply this information; but this only my opinion.

  4. Default
    I am new to this practice - OB-GYN - and am expected to begin chart audits. I do not have any experience with this. Does anyone have any reference information they could pass along to me?
    i.e web sites, publications, etc.?
    Thanks!

  5. #5
    Location
    North Carolina
    Posts
    3,126

  6. #6
    Default OB-GYN chart audits
    Lana, you definitely want to get some OB-GYN specific chart audit training if you haven't done this before. You might check out the American College of Obstetrics and Gynecologists' Coding and Nomenclature web page http://www.acog.org/departments/dept_web.cfm?recno=6 and see if there are any chart auditing seminars/workshops near you that you could attend for some specialty-specific audit training. The AAPC might also sponsor chart auditing workshops that also provide CEUs so check with them too. Good luck!

    Quote Originally Posted by LanaW View Post
    I am new to this practice - OB-GYN - and am expected to begin chart audits. I do not have any experience with this. Does anyone have any reference information they could pass along to me?
    i.e web sites, publications, etc.?
    Thanks!

  7. Default
    Thank you!!!!

  8. Default
    Thank you so very much!!!!

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