# Double Dipping On Em?



## geminitc81 (Oct 26, 2008)

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?


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## Susan (Oct 26, 2008)

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!


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## mkj2486 (Oct 27, 2008)

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.


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## pamtienter (Oct 27, 2008)

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.


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## geminitc81 (Oct 27, 2008)

Thanks Alot For All Your Response
Its What Was Going On In My Brain But Just Making Sure......


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## FTessaBartels (Oct 28, 2008)

*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


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## geminitc81 (Oct 28, 2008)

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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