# Ros-Cardiorespiratory



## Naveen Rachagolla (Dec 5, 2012)

REVIEW OF SYSTEMS: HEENT - Non-contributory. Cardiorespiratory - Patient has shortness of breath. Gastrointestinal - Non-contributory. Genitourinary- Non-contributory. Musculoskeletal - Non-contributory.

Does this count as Pertinent or Extended ?

Iam not sure of how to count if there is something like this *Non-contributory*.

Do i have to count only one for Cardiorespiratory - Patient has shortness of breath or can i aslo give credit for others which are non- contributory ?

Need some Help.


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## Pam Brooks (Dec 5, 2012)

This is Problem Focused with only one ROS.    "Non contributory" cannot be counted in ROS.  Providers must ask and comment on system review (pertinent positives and negatives).  The only acceptable other method is to document the pertinent systems and then state "All other systems were reviewed and are negative".  Remember, this is a subjective finding.  Providers are asking patients questions about their symptomology (or lack thereof).  What patient is going to respond, "non-contributory?"  The provider has made a judgement statement here, based on what the patient may or may not have answered.  He has to comment on the patient's sytem review, even if he doesn't think it impacts the presenting problem.  

In this case, the "Cardiorespiratory" is only "Respiratory".  SOB was the only comment, and that would not fall under cardiac.


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## Naveen Rachagolla (Dec 5, 2012)

Pam Brooks said:


> This is Problem Focused with only one ROS.    "Non contributory" cannot be counted in ROS.  Providers must ask and comment on system review (pertinent positives and negatives).  The only acceptable other method is to document the pertinent systems and then state "All other systems were reviewed and are negative".  Remember, this is a subjective finding.  Providers are asking patients questions about their symptomology (or lack thereof).  What patient is going to respond, "non-contributory?"  The provider has made a judgement statement here, based on what the patient may or may not have answered.  He has to comment on the patient's sytem review, even if he doesn't think it impacts the presenting problem.
> 
> In this case, the "Cardiorespiratory" is only "Respiratory".  SOB was the only comment, and that would not fall under cardiac.



Thank you Pam, 
But i still have some doubt on this to arrive to level 99221(Initial Hospital admission), because this code needs all the 3 out of 3 components and more over History requires 3 components for a level, but the minimum history and Exam is detail for this code but ROS is pulling it down to EPF history, can i still code the least level 99221 even if the History is not meeting the minimum level ?


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## Pam Brooks (Dec 6, 2012)

No you cannot.  If this is an admission note (I sure hope not) by your attending provider, you don't have a billable service at all. You cannot bill a subsequent code for an initial visit (for an admit).  This is simply a missed revenue opportunity.  Providers have to do better than this for an admission note.  


However, If it's a Medicare consult, and you're re-coding it to an initial hospital visit in exchange for a non-consult code, you can bill out a subsequent hosptial visit.


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## Naveen Rachagolla (Dec 6, 2012)

Pam Brooks said:


> No you cannot.  If this is an admission note (I sure hope not) by your attending provider, you don't have a billable service at all. You cannot bill a subsequent code for an initial visit (for an admit).  This is simply a missed revenue opportunity.  Providers have to do better than this for an admission note.
> 
> 
> However, If it's a Medicare consult, and you're re-coding it to an initial hospital visit in exchange for a non-consult code, you can bill out a subsequent hosptial visit.



Pam here is the chart which iam talking about and the system is accepting only 99221.

Can you give your outcome on this ?

*CHIEF COMPLAINT:* "I got a lot of stress and I have suicidal thoughts."

*HISTORY OF PRESENT ILLNESS*: Male patient had been seeing his primary care physician for anxiety and depression since 2001. This began with job related stress and he was a supervisor and was on 24-hour call. The patient became increasingly depressed and began isolating and staying in bed on his day off.  He was also pastoring a church which he gave up after he was unable to focus on church matters. In addition, he co-signed notes for two of his sons for cars but they did not make payments and he eventually had to file Chapter 7 bankruptcy. The patient has been on disability since July of 2001 for "mental reasons." On this day of admission, he received a call from the IRS saying that he owed them 12,000 dollars on taxes related to his disability income. He was on short-term disability for 26 weeks and now is on permanent disability. In addition, the patient's wife is bipolar and is having psychiatric treatment presently and she has good and bad days throughout the week. The patient has depressive symptoms of crying, insomnia, anorexia with recent 20-pound weight loss, decreased concentration, psychomotor retardation, suicidal ideation with plan. When the IRS told him he owed them money, he told the woman who called to wait and he was going to get his shotgun and she would hear him make his payment. In addition, the patient has auditory hallucinations and hears vague voices talking to him. He also will hear his wife call him when she Is not present. At the present time, the patient has been taking Wellbutrin 150 milligrams daily, Lexapro 20 milligrams daily and Xanax 1 milligram three times a day. He also uses a Combivent inhaler. He has been to the emergency room on several occasions for panic and anxiety attacks and he was treated symptomatically and released.

HPI is (Extended (4 or more HIP components qualify for Extended HPI))

*PAST PSYCHIATRIC HISTORY*: Is as noted above. There is no evidence of physical, emotional or sexual abuse as a child and there is no evidence of substance abuse. He denies any family history of emotional illness.

*MEDICAL AND SURGICAL HISTORY*: At work the patient was moving a chlorine tank which ruptured and he inhaled chlorine gas and was hospitalized for a week. He also has asthma and sinus problems.

*FAMILY HISTORY:* His wife as previously noted has bipolar disorder. One son has problems with anger management and is currently disabled because of this.

*SOCIAL HISTORY:* The patient has a high school education. He worked for 38 years before he was disabled. He feels that he gets along well with people. His marriage is solid but his wife's mental problems which have been going on for five for seven years causes him stress.

*PFSH is COMPLETE*

*REVIEW OF SYSTEMS*: HEENT - Non-contributory. Cardiorespiratory - Patient has shortness of breath. Gastrointestinal - Non-contributory. Genitourinary- Non-contributory. Musculoskeletal - Non-contributory.

*ROS is Pertinent (only one system was reviewed that is Cardiac and Non-contributory is not counted or qualified for ROS)*

*PHYSICAL EXAMIATION*: Is per emergency room physician.
RECTAL AND GENITALIA: Deferred to local physician.  
NEUROLOGIC: See neuro flow sheet.
MENTAL STATUS EXAM: Patient is a will nourished, well developed white man in moderate to marked distress. He is tearful during the initial interview. His mood is depressed and his affect is appropriate for the situation. Stream of mental activity is unremarkable; there is no evidence of delusions or ideas of reference. He does have auditory hallucinations. He appears to be of average intellectual functioning. His memory is good for remote and recent events. His general knowledge Is good. Insight and judgment are fair. INVENTORY OF STRENGTHS AND WEAKNESSES: Patient's primary strength is his recognition of illness and willingness to accept help. Weaknesses include difficulty in dealing with stressful situations and difficulty in controlling impulses at times.

*EXAM is Detail (Neurology, Psychiatric and Constitutionals)
For Detailed Exam (2-7 Organ Systems/Body Areas in Detail)*

DIAGNOSIS:

AXIS I
1. Major depressive illness, recurrent with suicidal ideation and plan and psychotic features.
2. Panic/Anxiety by history.
AXIS 11
1. No diagnosis.
AXIS III
1. Asthma.
2. Sinus problems.
3. History of chloride gas poisoning.   
AXIS IV
1. Psychosocial stressors; primary support.
2. Finances.
3. Wife's illness
AXIS V
1. Current GAP is 28, highest GAF past year 60.

*LABORATORY TESTS:* Routine laboratory work will be done and any abnormalities will be documented and addressed.

*TREATMENT PLAN:* Patient will have individual and group therapy. His Wellbutrin will be increased and he will be started on low doses of Seroquel which will be increased if psychotic symptoms are not abated. We will also advise him to get legal help.
PROBLEM SUMMARIES AND RECOMMENDATIONS; This 58-year-old married white male is admitted for treatment of depression with suicidal Ideation and psychotic features secondary to multiple stressors as noted in history and physical.

PROGNOSIS: Fair to good.
ESTIMATED LENGTH OF STAY: 7 to 10 days
DISCHARGE CRITERIA: Resolution of depression, suicidal ideation and auditory hallucinations, follow-up treatment plan in place.


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## Pam Brooks (Dec 7, 2012)

Ok this helps.

Remember, you don't have to obtain your ROS only from the paragraph titled ROS. Of course, it would be ideal if providers followed a nice, organized format, but in the real world, this rarely happens. In this case, you can get ROS from the HPI paragraph.  Unfortunately, EHRs will only calculate if the data is in the "right" place.   So based on what the note reads, here's what I came up with.  

*HISTORY OF PRESENT ILLNESS*: Male patient had been seeing his primary care physician for anxiety and depression since 2001. Timing This began with job related stress context and he was a supervisor and was on 24-hour call. The patient became increasingly quality depressed and began isolating and staying in bed on his day off. Modifying factors. He was also pastoring a church which he gave up after he was unable to focus on church matters. In addition, he co-signed notes for two of his sons for cars but they did not make payments and he eventually had to file Chapter 7 bankruptcy. The patient has been on disability since July of 2001 for "mental reasons." On this day of admission, he received a call from the IRS saying that he owed them 12,000 dollars on taxes related to his disability income. He was on short-term disability for 26 weeks and now is on permanent disability. In addition, the patient's wife is bipolar and is having psychiatric treatment presently and she has good and bad days throughout the week. The patient has depressive symptoms of crying, insomnia, anorexia with recent 20-pound weight loss, Constitutional ROS decreased concentration, psychomotor retardation, suicidal ideation with plan. When the IRS told him he owed them money, he told the woman who called to wait and he was going to get his shotgun and she would hear him make his payment. In addition, the patient has auditory hallucinations and hears vague voices psych ROS talking to him. He also will hear his wife call him when she Is not present. At the present time, the patient has been taking Wellbutrin 150 milligrams daily, Lexapro 20 milligrams daily and Xanax 1 milligram three times a day. He also uses a Combivent inhaler. He has been to the emergency room on several occasions for panic and anxiety attacks and he was treated symptomatically and released.

You have a detailed history right here, because PFSH were addressed in full later on. 

The exam makes reference to the neuro flow sheet.  If that was completed by him, and contains information regarding muscle strenghth and tone, gait and station and speech, then you have a comprehensive psych exam based on 1997 guidelines. Otherwise it's detailed. 

By audit, high risk, with a New patient with workup planned, in a patient with suicidal ideation and hallucinations (psychotic features). 

This meets a 99221 because of the limited ROS and likely detailed exam.   

Hope this helps. Pam


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## Naveen Rachagolla (Dec 7, 2012)

Pam Brooks said:


> Ok this helps.
> 
> Remember, you don't have to obtain your ROS only from the paragraph titled ROS. Of course, it would be ideal if providers followed a nice, organized format, but in the real world, this rarely happens. In this case, you can get ROS from the HPI paragraph.  Unfortunately, EHRs will only calculate if the data is in the "right" place.   So based on what the note reads, here's what I came up with.
> 
> ...



Pam once again Thank you, and i greatly appreciate your contribution. You really have good interpretation skills.


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## LLovett (Dec 10, 2012)

*May depend on who your carrier is*

I just wanted to add to Pams comment about this not being billable if the all 3 components do not meet the minimum requirements for initial visits. WPS Medicare and a few others are on record as saying that if the minimum requirements are not met for the initial you can drop down to subsequent care codes.

Check with your carrier to be sure.

Laura, CPC, CPMA, CEMC


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## MikeEnos (Dec 10, 2012)

*Non-contributory vs Negative*

This looks like a great educational opportunity for your provider - it appears to me as if they are using the term 'non-contributory' when they mean negative.  There's no way that provider listed out those ROS elements just to identify them as non-contributory.  What they most likely meant to document was that they were negative (maybe they thought writing non-contributory means it did not contribute to the chief complaint, in other words negative?)

I would ask them that question, and if my suspicion is correct all they need to do is use the word "negative" in that situation instead of non-contributory and they're documentation techniques will have improved greatly going forward - making your job easier!


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## MikeEnos (Dec 10, 2012)

Found some interesting information from Novitas - check with your local carrier to see what their stance is:

https://www.novitas-solutions.com/faq/partb/pet/lpet-evaluation_management_services.html#22 

*Under limited circumstances, could the term “noncontributory” be used as appropriate documentation to support the review of systems (ROS) and family history sections of the history component of an evaluation and management service (E/M)?*

It is understood that there may be circumstances where the term "noncontributory" may be appropriate documentation when referring to the ROS and/or family history sections of the history component of an E/M service. Under the E&M documentation guidelines, it is noted that, "those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented."  The use of the term "noncontributory" may be permissible documentation when referring to the remaining negative review of systems. The term "noncontributory" may also be appropriate documentation when referring to a patient's family history during an E/M visit, if the family history is not pertinent to the presenting problem. 

Date Posted: 10/16/2009, Date Revised: 10/01/2012


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## Naveen Rachagolla (Dec 10, 2012)

LLovett said:


> I just wanted to add to Pams comment about this not being billable if the all 3 components do not meet the minimum requirements for initial visits. WPS Medicare and a few others are on record as saying that if the minimum requirements are not met for the initial you can drop down to subsequent care codes.
> 
> Check with your carrier to be sure.
> 
> Laura, CPC, CPMA, CEMC



Thanks for all your contribution, and if such case comes in the Exam what should i do, because in real world we do audit and bill as per the payer, but what about from CEMC Exam point of view any specific gudelines ?


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## MikeEnos (Dec 11, 2012)

The exam is from the AAPC so you should follow CPT guidelines, DO NOT select answers based on how your local Medicare carrier requires something to be documented, or how your local Blue Shield carrier wants you to code something.  That's very important! 

That said, _*AAPC carefully selects the cases for the exam*_- they aren't going to give you an example that doesn't fit any criteria and ask you to make a judgement call.  If you think that's happening, there's a good chance you missed something.  Remember: it is multiple choice, and the cases were selected by the AAPC so it should fit the CPT criteria, or be addressed in the guidelines.

In real life there are a lot of grey areas, but there shouldn't be any on standardized tests.


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## LLovett (Dec 11, 2012)

I agree with Mike, they aren't trying to trip you up with different payer guidelines like that on the exams. It will be strictly based on CPT guidelines.

A tip that I give for all coding exams which is especially pertinent on the CEMC is to read the question and answers first. Find out what they are looking for before you read the note that goes with the question. There were many in my exam that the notes were 2 pages but the question was something very basic that did not require audting the entire note.

Work smarter, not harder. Don't over think any of the questions on the exam. You can always write notes in your test booklet if you feel something wasn't clear or disagree with the answers provided.

Good luck!

Laura, CPC, CPMA, CEMC


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## RebeccaWoodward* (Dec 11, 2012)

*Palmetto's view...*

As Mike has said before, each carrier has a different view on the term "noncontributory".  My Medicare carrier does not allow this statement.

Jurisdiction 11 Part B 
Is it acceptable to use 'noncontributory, unremarkable or negative' when reporting past, family or social history?

Answer: 
No, because the statement 'noncontributory, unremarkable or negative' does not indicate what was addressed. Did the nurse or physician ask specific conditions (i.e., any family history of coronary artery disease)? If for some reason you cannot obtain the family history, the documentation must support the reason why (e.g., the patient was adopted). 

Resource(s):

E/M Documentation Guidelines 



last updated on 10/02/2012

http://www.palmettogba.com/palmetto...Asked Questions~EM~8EEM6K6862?open&navmenu=||


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## Lynda Wetter (Dec 12, 2012)

HISTORY OF PRESENT ILLNESS: Male patient had been seeing his primary care physician for anxiety and depression since 2001. Timing This began with job related stress context and he was a supervisor and was on 24-hour call. The patient became increasingly quality depressed and began isolating and staying in bed on his day off. Modifying factors. He was also pastoring a church which he gave up after he was unable to focus on church matters. In addition, he co-signed notes for two of his sons for cars but they did not make payments and he eventually had to file Chapter 7 bankruptcy


Hope I'm not too far off on this...
What is listed as TIMING here should'nt that be Duration? Timing refers to the interval of pain or suffering (example) "every night", "in the middle of the night", "comes and goes"
Durationis is an approximate duration of the symptoms (example) "for the last 2 weeks", since yesterday", "fell this morning"

And for modifiying factors its information about how the sign or symptom is modified (example) "pain is relieved by standing erect", Headache somewhat better after taking asprin" 
I dont see the outcome of the factor listed here.


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## FTessaBartels (Dec 14, 2012)

*Hpi*

HISTORY OF PRESENT ILLNESS: Male patient had been seeing his primary care physician for anxiety and depression *since 2001* (timing). This began with *job related stress * Context)and he was a supervisor and was on 24-hour call. The patient became increasingly *depressed and began isolating and staying in bed on his day off* (severity). He was also pastoring a church which he gave up after he was unable to focus on church matters. In addition, he co-signed notes for two of his sons for cars but they did not make payments and he eventually had to file Chapter 7 bankruptcy. The patient has been on disability since July of 2001 for "mental reasons." On this day of admission, he received a call from the IRS saying that he owed them 12,000 dollars on taxes related to his disability income. He was on short-term disability for 26 weeks and now is on permanent disability. In addition, the patient's wife is bipolar and is having psychiatric treatment presently and she has good and bad days throughout the week. The patient has *depressive symptoms of crying,* (associated symptoms)insomnia, anorexia with recent 20-pound weight loss, decreased concentration, psychomotor retardation *I would count these are ROS - constitutional and psych)*, suicidal ideation with plan. When the IRS told him he owed them money, he told the woman who called to wait and he was going to get his shotgun and she would hear him make his payment. In addition, the patient has auditory hallucinations and hears vague voices talking to him. He also will hear his wife call him when she Is not present. At the present time, the patient has been *taking Wellbutrin 150 milligrams daily, Lexapro 20 milligrams daily and Xanax 1 milligram three times a day* (modifying factors). He also uses a Combivent inhaler. He has been to the emergency room on several occasions for panic and anxiety attacks and he was treated symptomatically and released.

As Pam said ... you do not have to limit yourself to the paragraph "titled" ROS ... 

IN GENERAL ... I first count HPI elements ... if I do not have FOUR, then I only need 1 pertinent system in ROS for a EPF history (New patient / consult level 2)

If I DO have 4 .... I then look for ROS.  If I do NOT have 10, then I only need 2 systems of ROS and 1 element of PFSH for the Detailed history (Admission level 1, or New patient/consult level 3).

If I DO have 10 systems (or more) ROS ... I look for PFSH.  I need at least 1 item documented in each area of medical/social/family history to get a Comprehensive history.  If I am missing any one of these, I have a DETAILED history.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## lodawnyoung (Dec 18, 2012)

What an educational thread, thanks to all the contributors.
I know "noncontributory" does not count in a ROS. What about saying "other than his current complaint is unremarkable"?


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