Wiki ROS And Pt not Able?

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jifnif

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I have as a review of systems that due to the patient's mental status ROS could not be obtained. Can this be counted as a complete? And either way, is there a source of documentation on that? I have a dr saying he knows this counts and either way I want to have a place that I can say it is stated clearly. Thanks ahead. :)
 
If you document what you tried to get and why you couldn't get it; you get the credit for it.

Most often the MD will get something from the chart, floor nurse, office MA, etc. But, when talking with the patient if the MD cannot elicit any further information it is acceptable to mention as indicate above.

Suzan
 
I cannot locate the documentation right this second because I really do not have the time right now. However, I did want to let you know that, yes, full ROS counts if the doctor documents unable due to patient condition, such as altered mental status. I will provide you with documentation when I get the time to find it for you.
 
"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."


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

If the provider made every attempt to provide a ROS from lets say...family, EMT, caregiver, previous records, etc....and documents thoroughly why the information is unobtainable...intubated, unconscious, severly demetia, etc...I would allow credit.
 
Thank you sooooo much! I really appreciate the fast response. Also, whenever you get the source for that please just post or message me. Thank you again, Jennifer

Oh, i posted same time as the previous message. Thank you sooo much for posting that source!
 
99499 Unlisted E/M

Okay - don't shoot the messenger ...

I was at a coding symposium devoted to E/M last month. Our Medicare rep (WPS in WIsconsin) stated that NO credit would be given for "unable to obtain ROS / PFSH," regardless of the reason for not being able to get it.

Rather, WPS would expect to see this coded as 99499 with documentation provided. You would price equivalent to the E/M level you WOULD have coded had you been able to obtain the ROS/PFSH.

Remember ... don't shoot the messenger. I strongly disagree with his position, but he said it multiple times. (Boy, am I glad I'm in pediatrics!)

F Tessa Bartels, CPC, CEMC
 
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