Wiki Established, ROS: NONE...99212?

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0774tankersley

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Ok, so alot of my providers will have established visits and put them in as 99213, 99214 but they will not preform an ROS. the ROS will read "none". I have been down coding these visit to 99212 due to them not having included a required component of the history documentation and 99212 is the only level for which its not required. I have an audit book that states that with out a ROS the note will only qualify for a 99212 as well, but then I started thinking for established its only 2/3 so if the exam and mdm support maybe I should let it go as a 99214...but deep down this still doesnt make sense because how could a high level decision be made with out a decent history?

Any help or reference would be greatly appreciated!
 
It would be fabulous if all providers documented in a nice neat package, with all history elements under "HISTORY", and all ROS elements in the correct place. But what I frequently find is that as providers dictate or use their EHRs, they often place exam components in comments in the Assessment, and ROS components in the history. Bottom line: if you are able to abstract language to support any of the key components that are related to the Chief complaint within the language of the document, you can count it. For example, one of our hospitalists always went into a great deal of history while discussing the patient plan, providing a nice overview of the case before he then went on to outline the plan, so that I could use that for the history/ROS. It's ok to pull information from other parts of the note, as long as you don't double dip (use a history element twice, for example). Medical necessity and the nature of the presenting problem are just as important as counting bullets.
 
Agree with Pam, if the ROS isn't complete or isn't there, I try to pull from the HPI/CC to get my additional elements. But as she said, it's important not to "double dip!"
 
I agree totally. I am constantly have to pull ROS from the HPI portion of the note!

In a perfect world all the documentation would be where you would expect to find it, but that is not always the case.

As Pam said, be careful about double dipping. Providers will do that unknowingly and try to send a higher charge that may need to be backed down.
 
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