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Double Dipping On Em?

  1. #1
    Location
    Traverse city/ Detroit
    Posts
    48
    Default Double Dipping On Em?
    Exam Training Packages
    Ok So Here Goes
    For The Ros Can I Use From The The Physical Exam Bullets?
    For Example For A 99213 Dr Is Checking More Than 7+ Orgn Systems, And Only One Bullet For The Ros. And Im Wondering If It's Ok Take From The Physcial Exam Bullets To The Ros For It To Equal Out As A 99213 Or Is This Unethical Or Double Dipping?

  2. #2
    Default
    Easy answer here for you...

    You may NOT use your examination for ROS, period.

    If you have an established patient visit you don't have to use the history component in choosing your code. Just be sure your Medical Decision Making and Exam meet the criteria as per the guidelines.

    Hope that helps!
    Susan Ward, CPC, COC, CPC-I, CEMC, CPCD, CPRC
    AAPC ICD-10 Expert Trainer
    susanwardcpc@live.com

    A small act of kindness a day can make someone's day special

  3. Default
    Also, depending on how much HPI is given, once you get enough elements to meet the level of service, you can pull what you need from the remaining HPI for your ROS.

  4. #4
    Default
    The ROS is an inventory of the body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced and the patient's responses related to the problem are documented. The exam results are from an actual exam - listening to the heart and lungs, inspecting HEENT, etc, so these two aren't interchangeable.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I, AAPC Fellow
    AHIMA Approved ICD-10-CM/PCS Trainer
    AAPC National ICD-10-CM Trainer

  5. #5
    Location
    Traverse city/ Detroit
    Posts
    48
    Default
    Thanks Alot For All Your Response
    Its What Was Going On In My Brain But Just Making Sure......

  6. #6
    Location
    Milwaukee WI
    Posts
    4,466
    Default I agree, but
    I agree - in general - but sometimes physicians are not so neat and clean in their dictation.

    I've seen notes that are all one paragraph (go ahead, roll your eyes - I know I did) and it's up to the coder to decipher where the history / exam / and MDM are divided.

    I've also seen notes that are neatly subheaded: HPI, ROS, PFSH, Exam, etc
    but when you read them, there might be something in the exam section such as "patient denies any previous fainting spells."

    If that's the case, I might pull a statement like the above example out of the "exam" section and use it for ROS. (It's really not a description of examination findings, afterall.)

    F Tessa Bartels, CPC, CPC-E/M

  7. #7
    Location
    Traverse city/ Detroit
    Posts
    48
    Default
    The Sheet They Right In Is Already Formated Hpi,ros,exam,assment And Plan, And They Handwritie So There Is No Dictation (which I Wish There Was.) But I Do Understand What Your Getting At.

    Thank You

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