Wiki Getting ROS from a patient with dementia

[CatchTheWind]

CORRECTION: SUBJECT SHOULD HAVE SAID PFSH, NOT ROS!

One of my providers is complaining that she is unfairly being denied a higher level E/M because she is unable to get a past, family, and medical history due to the patient's dementia.

My tentative reply to her is that there are other sources for a PFSH. She could find it in previous records, contact a family member, etc.

Since I am not entirely certain that I am correct about this, I wonder if anyone else knows for certain?

Thanks!

 

[thomas7331]

The 1995 and 1997 documentation guidelines say that 'if the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history' but don't give any further guidance as to whether or not this means the provider should get credit for a full history. The general consensus I think is that if the provider documents why they were not able to obtain certain information in the history, then you would code based on the remaining elements in the note. In other words you would not penalize the provider for the missing unobtainable elements but also not reward them with history that isn't there either. Hope this helps some.

 

[CatchTheWind]

Thanks a lot! Question: What did you mean by not punishing, but also not rewarding the provider? Do you mean coding as though there were no requirement for PFSH?

 

[Jlokloski]

There are instances where the provider might not be able to
obtain a history from the patient. For example, the patient
presents unconscious or has dementia. In this case, the
provider must make an effort to obtain history from another
source, such as a family member, EMS bringing the patient to
the emergency room, or the patient’s primary care physician.
If the provider cannot obtain the history from the patient or
other source, he or she must document the patient’s condition
or other circumstance that prevented him/her from obtaining
the history.

At the WPS seminar this question was asked and they stated that since the ROS was unobtainable due to the patients condition, you could only give the level that was obtained without the ROS since it does not state that the provider automatically gets the complete ROS and comprehensive history.

Unfortunately, you could probably get a different answer depending who you ask since this is not set in stone in the guidelines.