Wiki ROS & Exam Confusion

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Radcoder86

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Can exam elements be counted towards the ROS?

Also, I'm confused about how you count elements in the exam. I have providers that list off body areas and organ systems, but I've read you can't count both? So if I have a doctor that lists neck and HEENT and multiple other organ systems, can I not count neck since I'm counting organ systems?

Thanks!
 
Exam and ROS are two different things - exam would be the objective findings of the provider when they examine the patient whereas the ROS are the patient's answers to the questions asked about what symptoms they are experiencing, so those two are not interchangeable.

For counting exam elements, in the 1995 guidelines, the EPF and detailed exams are based on the 'affected body area or organ system and other symptomatic or related organ system(s)' but the guidelines don't give much more specific information than that. I think most coders and auditors count one or the other, but not both within the same note, so you would not count neck if you are basing your coding or audit on organ systems, but again the wording of the guidelines doesn't make that a hard and fast rule. Your payers might provide more specific direction on this, as the 1995 guidelines are pretty general.

Hope this helps some.
 
Radcoder86 said:
Can exam elements be counted towards the ROS?

Also, I'm confused about how you count elements in the exam. I have providers that list off body areas and organ systems, but I've read you can't count both? So if I have a doctor that lists neck and HEENT and multiple other organ systems, can I not count neck since I'm counting organ systems?

Thanks!
Click to expand...

You cannot count body areas and organ systems together. However if the doctor documents, neck and then states under that heading something about the lymph nodes or thyroid gland, then you can count that information towards the lymphatic system. It is not necessarily the heading you go by - it is the information that they provide under that heading as to whether it is a body area or an organ system.
 
I have a question I think I know the answer too but want confirmation. A patient CC pt complaining of diarrhea & lab work. during the ROS, which all were performed fatigue and malaise were mentioned, toward the button of the note NP draws hormonal, and thyroid labs. Her DX is missing uterus, hypothyroid and metabolic syndrome.

Nothing else documented shouldn't the provider have documented that she ordered labs due to patient feeling fatigue and malaise? Or is her putting the fatigue and Malaise under the ROS enough
 
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