Wiki ROS and reviewing doc for sect B

[Jenna000]

I have two questions:
1. Can a dr use another DRs ROS that is in the same group and practice, if they can what are the requirements they need to have stated?

2. In the MDM letter B it it says review and summarization of old records and or obtaining history from someone other than the pt, and the next one down is independent visualization of image,tracing or speicmen.
When the DRs have in there dictation very speicific details about a past cardiology history (i will use my specialty, since in this case that is what they are referring to) but not the source of the information, can you count that, i would have to have been from a record somewhere if they are going back through the cardiac history?
--For independent review, do they have to say per my reivew, or something similar or is the details of the report good?

i guess that is 3 questions...
thanks in advance for any help,
Jenna

 

[gailgordon314]

Can a dr use another DRs ROS that is in the same group and practice, if they can what are the requirements they need to have stated?

I've never seen it done and wouldn't advise it. An ROS is subjective based on the leading type questions your doctor asks the patient.

In the MDM letter B it it says review and summation of old records and or obtaining history from someone other than the pt, and the next one down is independent visualization of image,tracing or specimen.I've really only seen this done with a specialist who is reviewing a consult request from a primary care physician or in the case where the patient is unable to give a history ie: dementia. You can count those items as a point toward your E/M providing the doctor specially states he reviewed the notes because the time to review those notes and prepare for a medically complex patient may be counted towards an e/m (most surgeons/specialists will do this. Or if the info was obtained from a family member due to patient's dementia or injury often seen in Primary care or neurology.

 

[dmaguire]

1. Can a dr use another DRs ROS that is in the same group and practice, if they can what are the requirements they need to have stated?
Currently we tell our providers they can use past ROS but they have to tell the date they are pulling it from in order to get credit. Per Medicare they state: "The review and udpate date my be documented by: noting the date and location of the earlier ROS and/or PFSH."

For independent review, do they have to say per my reivew, or something similar or is the details of the report good?

We require our providers to say "per my review" or to make it obvious its their own interpertation of the report.

Hope this helps. Danielle