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Help Can you use Phy. Exam for ROS

  1. #1
    Question Help Can you use Phy. Exam for ROS
    Medical Coding Books
    I need help!

    We have 4 HPI, 2 PFSH, 6 ROS, and 13 Phy. Exam. We need 9 ROS and only 8 Phy. Exam in order to charge a level 5. Can we use the extra Phy. Exam for the 3 ROS that we are missing as long as we are not duplicating the areas?

    Can anyone out there please help me!!!!!

  2. #2
    Dover Seacoast New Hampshire
    99.9 percent of the time you cannot, if the examination reports only objective data. Let me explain....

    The ROS is part of the subjective data capture. (asking the patient, rather than the provider determining on their own with a hands-on evaluation). The objective (exam) can actually be done without the patient's participation, and is the providers independent evaluation of the patient's physical status through a systematic examination.

    You can't mix and match the two.

    I have seen, however, in a very few handwritten or dictated notes instances where History or system comments made in the examination portion of the note could be counted as History, for example, when examining the MS system, the provider also notes, "patient reports that pain is a 7 on a scale of ten". Technically, this is subjective...the patient has told him this, it's not something he could ascertain from an exam only. But this is not the norm, and I wouldn't ever advise that you pull History or ROS data from the examination as a matter of course.

    So I'd say, no you can't.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. #3
    Thank you for your help

  4. #4
    Milwaukee WI
    Default Duplicate question
    THis is a duplication question ... I answered in the other thread.

    Basically, No. The Exam is not interchangeable with the ROS.

    F Tessa Bartels, CPC, CEMC

  5. #5
    I agree... you cannot take from the PE... but sometimes you may pull some from the HPI .... but I would be careful because you cannot use the same information twice.... AND.... it will not give you enough to make your level 5....
    Susan Edwards, CPC, CEDC, AAPC Fellow
    Swainsboro/Statesboro Georgia President

  6. #6
    Another thought.... this would be a good example to show your physician......
    Susan Edwards, CPC, CEDC, AAPC Fellow
    Swainsboro/Statesboro Georgia President

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