# E/M university case of the week



## cpccoder2008 (Jul 28, 2009)

http://www.emuniversity.com/COW/case072809.pdf

I am a little confused on the explanation he gives for the ROS. *ROS: No chest pain or shortness of breath*. He states that 2 systems were reviewed which i agree but he states it was Gastro and Cardio/Pulmonary. I think it should be gastro and respiratory. Does anyone else agree with him and if so where do i find documention stating that those statements should fall under the cardio ROS ?

Thanks in advance !!


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## Orthocoderpgu (Jul 28, 2009)

The complete ROS states: Positive for intermitent nausea and vomiting (GI) No chest pain or shortness of breath (CV).

I do these too and have learned a lot. This is how I intrepret it.


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## cpccoder2008 (Jul 28, 2009)

I thought the statement *No chest pain or sob* was a Respiratory ROS. According the this handout it would be counted as Resp.
http://medinfo.ufl.edu/year1/epc97/handouts/ros.html
But in the case review he states it's cardio/pulmonary. I am just really confused on what system it should be associated with.


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## RebeccaWoodward* (Jul 28, 2009)

CMS provides an example in the DG's.....

Extended, which inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems. In the following example, two systems – *cardiovascular and respiratory *– are reviewed: 

CC: Follow up visit in office after cardiac catheterization. Patient states “I feel great.” ROS: Patient states he feels great and *denies chest pain*, *syncope, palpitations*, and *shortness of breath*. Relates occasional unilateral, asymptomatic *edema* of left leg.

http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

Page 11 of first link


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## cpccoder2008 (Jul 28, 2009)

So would the Chest pain be a ROS for Cardio and the SOB for Resp ? Then that would make 3 ROS instead of 2 like stated in his explanation. The paragraph under that statement says

 3) Complete, which inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of 10) body systems. In the following example, 10 signs and symptoms are reviewed: CC: Patient complains of “fainting spell.” ROS:
o Constitutional: weight stable, + fatigue.
o Eyes: + loss of peripheral vision.
o Ear, Nose, Mouth, Throat: no complaints.
o *Cardiovascular:* + palpitations; *denies chest pain*; denies calf pain, pressure, or edema.
o *Respiratory*: + *shortness of breath *on exertion.
o *Gastrointestinal*: appetite good, denies heartburn and indigestion. + *episodes of nausea. Bowel movement daily*; denies constipation or loose stools.
o Urinary: denies incontinence, frequency, urgency, nocturia, pain, or discomfort.
o Skin: + clammy, moist skin.
o Neurological: + fainting; denies numbness, tingling, and tremors.
o Psychiatric: denies memory loss or depression. Mood pleasant.


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## cpccoder2008 (Jul 28, 2009)

In the case study it states :
ROS: Positive for intermittent nausea and vomiting. Negative for melena or hematemesis. No chest pain or shortness of breath.


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## RebeccaWoodward* (Jul 28, 2009)

Personally, I scored *3 ROS*. Not sure how/why he mentioned 2 (statement copied from his assessment_...."Two systems are reviewed: gastrointestinal, cardiovascular and pulmonary.")_

ROS: Positive for intermittent nausea and vomiting (*GI*). Negative for melena or hematemesis (*GI*) . No chest pain (*Cardio*) or shortness of breath (*Respiratory*).


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## Lisa Bledsoe (Jul 28, 2009)

cpccoder2008 said:


> I thought the statement *No chest pain or sob* was a Respiratory ROS. According the this handout it would be counted as Resp.
> http://medinfo.ufl.edu/year1/epc97/handouts/ros.html
> But in the case review he states it's cardio/pulmonary. I am just really confused on what system it should be associated with.



Chest pain stated by itself is usually considered as cardiovascular.  If the note stated painful respiration that would qualify as respiratory.  Look at the definitions in the hand out you provided the link for; under Respiratory it provides examples of what kind of pain would be considered under the respiratory ROS.  (I hope that made sense...)


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## cpccoder2008 (Jul 28, 2009)

I first scored 2 because i didn't know that chest pain was considered cardio so i was adding 1 for chest pain and sob for Resp and 1 for gastro but after reviewing the documents you sent me i am counting three, the same as you. I just want to make sure i am understanding this right.


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## cpccoder2008 (Jul 28, 2009)

Lisa Curtis said:


> Chest pain stated by itself is usually considered as cardiovascular.  If the note stated painful respiration that would qualify as respiratory.  Look at the definitions in the hand out you provided the link for; under Respiratory it provides examples of what kind of pain would be considered under the respiratory ROS.  (I hope that made sense...)



Yes i understand now, after reading all the documents it started to be clearer. But am i right to say that there are 3 systems being reviewed instead of 2 ?


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## RebeccaWoodward* (Jul 28, 2009)

My opinion, yes.  


INTERVAL HISTORY: Patient continues to have constant gnawing mid-epigastric abdominal pain which is 8/10 in severity.

ROS: Positive for intermittent nausea and vomiting. Negative for melena or hematemesis. No chest pain or shortness of breath.

Mid egipastric abn pain can mask or mimic other underlying issues.  In this scenario, it's safe to credit 3 ROS.


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## cpccoder2008 (Jul 28, 2009)

I agree, thank you for reading my very long post  I'm a little rusty on the whole E/M and wasn't quit sure about the ROS.


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## RebeccaWoodward* (Jul 28, 2009)

Looks like you're on the right path to me!


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## LLovett (Jul 28, 2009)

My guess on why it would say 2 systems reviewed instead of 3, which I agree 3 were done, is because it doesn't make a difference. The levels of history are affected by 0 ROS, 1 ROS, 2-9 ROS, and 10+ ROS. 

I do the same thing myself, I will usually put 2-9 ROS when I audit instead of saying 6 or whatever it maybe. I do this to help reinforce to the providers they get no more credit for reviewing 9 systems than they do if only 2 systems were reviewed. Many times the ROS is what keeps my specialists from getting the comprhensive histories.

Just my take on it,

Laura, CPC


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## Lisa Bledsoe (Jul 28, 2009)

cpccoder2008 said:


> Yes i understand now, after reading all the documents it started to be clearer. But am i right to say that there are 3 systems being reviewed instead of 2 ?



Yes.  And I agree with Laura that perhaps he is only stating 2 because there needs to be 10 to go higher in the ROS.  That or it's just a typo on his part.


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## deeva456 (Jul 29, 2009)

I agree with 3 ROS... GI, CV and Resp. I have always counted SOB as respiratory.


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## Orthocoderpgu (Jul 30, 2009)

Yes, you are right. I asked Dr. J and his response was yes, the resp syst was reviewed. You can see it on the web site. Good catch !


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