Wiki ROS Documentation

[jackiemal]

I need some guidance. We are being told that if the patient is a pediatric patient under the age of 18 we are to automatically give credit for a complete ROS. Can someone help me out with this? I thought that it was just if the patient was unresponsive, there was no where to get the information (past records or family/friend), and the reason it was unobtainable has to be documented. Can anyone can give me a good source to explain this? I refuse to give credit like this and I'm being penalized!

Thank you,

 

[Pam Warren]

There was some discussion awhile back (unsubstantiated, by the way) that indicated you could get data points for obtaining history from anther person (parent) when treating a minor. Since this is typically the way all pediatricians obtain history information, there was the thought that this wasn't outside their normal E&M process, and it should be routinely counted as additional data points. However, I've never heard of obtaining a full ROS based on patient's age, only if the ROS is otherwise obtainable, and the reason is documented.

 

[jackiemal]

Thank you! We always have 3 or 4 bullets for a pediatric patients, either from the parent/guardian or the patient themselves. I don't think it is correct to give them a complete ROS. Unfortunately they won't stop penalizing me unless I can get something in writing from CMS or AMA. If anyone has any resources I would love to see it!