# ROS unobtainable



## Trendale (Mar 18, 2009)

Hello,
Can someone tell me how I should code an E/M in which the doctor states, " Please see medical record as review of systems is unobtainable based on patient being on a mechanical ventilator." I didn't think he can credit for it because he didn't say he reviewed the ROS in the patient's record. When I checked the chart, there was four ROs reviewed by another doctor from a differnt specialty  on the same day, even though the ROS is in the chart by another doctor, he did not review it, but I am not really sure. Should this be a 99252?


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## FTessaBartels (Mar 18, 2009)

*ROS counts*

Because the patient was on a mechanical ventilator your physician has a reason for not being able to take a complete ROS.

However, if the physician is relying on the medical record, he should indicate where in the record he obtained the information (e.g. H&P dated 3-10-09), and also indicate that he reviewed this information. 

Depending on how the rest of the documentation is written, I'd be inclined to give him credit for 99252 in this case because there is a presumption of a shared medical record for an inpatient and he at least mentioned that it is in the record. 

Another question for you ... as the patient is on a ventilator s/he is probably critically ill. Did you physician provide critical care services?

F Tessa Bartels, CPC, CEMC


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## becka95 (Mar 18, 2009)

On the highmark medicare site if you go to the E&M center on the Part B side there is a manual for E&M. In the manual it states that if a Physician states that he is unable to obtain the ROS due to the patient condition this is considered acceptable. Below is the linl for the manual. It is on page 8.

http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf

Hope this helps!


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## Trendale (Mar 18, 2009)

*Replyt o FTessa and becka 95*

He did not state he did critical care. He was requested by a pulmonologist to review the patien'ts condition and give his opinon. ( consult)

You said because the patient is on a ventilator, no ROS is accepted and this would constitute a 99252? The rest of the information in the other two components is extensive including the HPI in the history, but I know the rule is to code to the lowest. There is no exception in this scenario? Thanks!


Thanks Ftessa for your input, I will check that link out.


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## Trendale (Mar 19, 2009)

*Reviewed 97 E/M PG 8*

Hello,
I have reviewed the 1997 guidelines on pg 8. It stated if the history is unobtainable, the physcian should doucument the reason why, in this case he did. He stated this was a suicide attempt, patient consumed multiple narcotic drugs. The guidelines also stated he should supplement a statement confirming that he reviewed the ROS in the medical record by another physcian. In this case he did not state this, he stated "please see medical record as ROs was unobtainable", which brings it back to my original question, he did not state that he actually reviewed it. Based on the information  documented in the history, he bascically obtained the information from reviewing the record, because by the time he was called to the ER, the patient was already on the ventilator, so he did not speak directly to the patient. The attending physcian was able to obtain this information, as the patient was not on the ventilator yet. So I looked at the attending physcian's ROS and he documentd four ROS. The consulting doctor had to have either conversed with the attending doctor or looked at his documentaion in the medical record  in addition to test/labs to document his report. So I would agree with the 99252 based on the other doctor's ROS. If his ROS would have been detailed or comprehensive, the code would have been higher. 
Do anyone agree with this or have have a different perspective based on any other guidelines? Thanks!


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## wbradhoward (Jun 18, 2009)

We are currently debating this exact issue at my place of work.

It is my understanding that the physician has to be specific as to the reason why the ROS was unobtainable.  For instance "ROS was unobtainable due to patient being on a vent" would be an acceptable way to document this.

I agree that the statement "please see medical record as ROS was unobtainable" does not specify the reason why it was unobtainable, therefore should not accepted as a complete ROS.  Even if elsewhere in the record it states that the patient was ventilated or altered or whatever, the doc has to specifically state this as the reason the ROS is unobtainable. 

The reason for this need for specificity is that a patient can be on a vent and still able to supply a ROS.  A patient can have AMS and still be able to supply a ROS.  The doc has to quantify the issue as being severe enough to limit the ability to communicate with the patient.


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## dclark7 (Jun 19, 2009)

It is my understanding that because he documented the reason he could not obtain the history (pt on mechanical vent) he would get credit for the history. He then refers back to the medical record so he would get credit in the MDM (amount of data reviewed) for obtaining hx from the chart, I would give him credit especially if he reviewed lab, x-rays etc and documented the results since that is the proof that he reviewed the chart.

Doreen Clark, CPC


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## gailmc (Jun 19, 2009)

If the provider documents the history is unobtainable, he would get credit for this history, but only for elements that are normally pertinent to the visit.  Using "history unobtainable" should not make or break a LOS.


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## wbradhoward (Jun 19, 2009)

I'm sorry - I must have misread your post initially - re-reading it, I would agree that your doc's statement is sufficient.  Pt should credit for a complete ROS.


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