# e/m confusion



## ekfannin (Mar 6, 2013)

I am studying for the CPC exam and while I was talking to one of the billers in my office she made mention that if one of the doctors rounds at the hospital and the patient can't physically describe his review of systems then you would still code as if he had reviewed all systems even if he hadn't reviewed any.  Is that right? because to me it doesn't make sense if he reviewed no systems shouldn't you code it that way?


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## jimbo1231 (Mar 7, 2013)

*Caveat*

I think the biller was talking about the history "caveat". Basically if the patient is no condition to give an ROS, it is not required. But the physician needs to clearly document the reason the patient could not give the ROS. Also if there is another source like family member who could provide any history, the provider should use that resource. But the biller was pretty much correct.

Jim


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## MnTwins29 (Mar 7, 2013)

That might also be referencing the interval history in subsequent hospital visits where the physician doesn't need to keep documenting the same items if there is no change in the history on subsequent visits.   In my experience, I rarely use history in these visits as it is rarely documented.   And with only 2 of 3 key elements needed....


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## Lynda Wetter (Mar 7, 2013)

jimbo1231 said:


> I think the biller was talking about the history "caveat". Basically if the patient is no condition to give an ROS, it is not required. But the physician needs to clearly document the reason the patient could not give the ROS. Also if there is another source like family member who could provide any history, the provider should use that resource. But the biller was pretty much correct.
> 
> Jim



If the Doctor mentions why he can not obtain a ROS he does not get credit for a complete ROS right? thats just clarifying why it was not done and he gets "counted" as no ROS...right?


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## MikeEnos (Mar 8, 2013)

I've seen this question a lot lately.  You need to check with your local carrier.  My local carrier, NHIC instructs coders to give full credit for a Comprehensive history if the information is unobtainable.  Here is the exact quote from NHIC:



> *Important Note: Allow a comprehensive history if the physician is unable to obtain a history from the patient or other source. The record should describe the patient’s condition or circumstance that precludes obtaining history.*



Here's the link

Think about it, if the patient is rushed to the hospital, unconscious, no family present, and cannot provide a review of systems - why should the physician be limited to a level 1 admission??  That seems like a pretty serious case, I wouldn't be surprised if the provider felt it was a level 3 admission.... but without a detailed or complete ROS technically it doesn't even meet the requirements for a level 1 admission.... so keep that in mind.  

Same applies for Family history.  If the patient was adopted and cannot provide the physician with family history, don't fault the physician for that.  Give them credit for checking, even though they were unable to obtain the information.


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## Lynda Wetter (Mar 8, 2013)

MikeEnos said:


> I've seen this question a lot lately.  You need to check with your local carrier.  My local carrier, NHIC instructs coders to give full credit for a Comprehensive history if the information is unobtainable.  Here is the exact quote from NHIC:
> 
> 
> 
> ...



Thanks Mike I will definately chaeck the carriers ( I have to deal with 2 jurisdictions...ugh) But.... what if someone like me was sitting for the CEMC exam, what would I do in that case...if a question like that is on the exam!!!
Thanks in advance.


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## MikeEnos (Mar 8, 2013)

The thing about standardized tests is that the questions selected must have answers that are beyond dispute.  Since the test is given nationally, they won't put any questions on the test if the answer varies by region.


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## Lynda Wetter (Mar 8, 2013)

Thanks, I was just thinking that. I guess that can fall into the comment "There are no trick questions" I over think sometimes.


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