# Chart Auditing - ROS



## mbdk1977 (Jul 3, 2008)

I have recently completed an audit of some E/M codes and the group has a ROS, PFSH form.  The patient and physician are most often times signing it but they are leaving it blank.  Would you take that as having completed the review?


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## Lisa Bledsoe (Jul 3, 2008)

Not if it is blank.  There has to be something documented to cout.  A signature on a blank form doesn't cut it for me.


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## RebeccaWoodward* (Jul 3, 2008)

I agree with you, Lisa.  It's hard to give credit for blanks.  I know there are times when it's difficult to obtain this information (dementia, unconsciousness) but in normal circumstances, I feel an effort needs to be made.  PFSH and ROS aid in the building blocks of the level of the e/m. 

The ROS obtained on a previous visit does not have to be re-recorded, but all new information must be documented along with a notation stating where the previous information is located in the chart. Also, a review of the PSFH obtained during a previous visit does not have to be re-recorded but, again, new information must be listed along with a notation regarding the location of the previous PFSH.  

Some type of documentation is needed to record pertinent facts, findings and observations about a patient.  The physician will be held accountable for his documentation and as stringent as carriers are becoming, it's in his/her best interest to supply this information; but this only my opinion.


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## LanaW (Jul 3, 2008)

I am new to this practice - OB-GYN - and am expected to begin chart audits.  I do not have any experience with this.  Does anyone have any reference information they could pass along to me?
i.e  web sites, publications, etc.?
Thanks!


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## RebeccaWoodward* (Jul 3, 2008)

http://www.cms.hhs.gov/MLNEDWebGuide/25_EMDOC.asp

Good luck to you!


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## Mark Wills (Jul 3, 2008)

*OB-GYN chart audits*

Lana, you definitely want to get some OB-GYN specific chart audit training if you haven't done this before.  You might check out the American College of Obstetrics and Gynecologists' Coding and Nomenclature web page http://www.acog.org/departments/dept_web.cfm?recno=6 and see if there are any chart auditing seminars/workshops near you that you could attend for some specialty-specific audit training.  The AAPC might also sponsor chart auditing workshops that also provide CEUs so check with them too.  Good luck!



LanaW said:


> I am new to this practice - OB-GYN - and am expected to begin chart audits.  I do not have any experience with this.  Does anyone have any reference information they could pass along to me?
> i.e  web sites, publications, etc.?
> Thanks!


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## LanaW (Jul 3, 2008)

Thank you!!!!


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## LanaW (Jul 3, 2008)

Thank you so very much!!!!


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