Wiki ROS if patiens is unconscious

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Naveen Rachagolla

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Hello, Fellow coders,

Can someone help me, How to take count If the Medical record is documented stating unable to take ROS because patient unconscious and there is no other sources to obtain ROS,
Should we take it as pertinent or Ext ended or FUll, I went through somany websites but i dint find any reliable source or document. If you have any document which addresses such things please help or the way how you work with such statements.

Thanks.
 
You can consider as full ROS and also you can consider the History portion as Comprehensive because the Physician tries his/her best to obtain History portion but Patient was not in a situation to provide. Hence consider the History as comprehensive. This is otherwise called as "E&M Caveat rule"
 
YES if because of any MEDICAL condition of patient such as loss of consciousness, sedated patient, dementia or any psychological case history is unable to obtain you can consider comprehensive history,

but it is physicians responsibility to state that history / ROS is unable to obtain or it is limited because of patients medical condition.
i hope that helps

ABHISHEK RANE CPC
 
Per 95 guidelines "If the physician is unable to obtain a history from the patient or other source, the record should describe the pateint's condition or other circumstance which precludes obtaining a history."

I would agree that a comprehensive history can be credited.
 
As an auditor who reviews a lot of ED charts, I come across this frequently. Absolutely the provider should not be faulted because the patient's condition makes it impossible to gather a Review of Systems, or Past Family history etc. If they document the reason it is unobtainable, give them full credit for trying. Whether the patient is unconcious, demented, intoxicated, or refuses to answer, I count it. I do urge them to state clearly that it is unobtainable... not something like "ROS was difficult to obtain" or "Patient's slurred speech made the ROS difficult." It's either possible or it's not. Don't say it was difficult.

Note - this same logic also applies if the Physician attempts to document family history but the patient was adopted. That's social history, but they should get credit for Family History because they TRIED to document it, but it is unobtainable.
 
I disagree

Some carriers may allow this but I would validate before I gave credit. WPS Medicare is very clear that they do not give credit in these situations.

http://www.wpsmedicare.com/j5macpartb/resources/provider_types/2009_0526_emqahistory.shtml

I personally can't find any documentation from a Medicare carrier stating they allow for a comprehensive history when it can't be done. I would be really interested in seeing the source information the other posters are basing their responses on.

Laura, CPC, CPMA, CEMC
 
I know this is an old thread, but what if the patient is sleeping? The doctor put "Pt sleeping at the time of examination and contributed only LE edema and Low back pain to me. More worried about getting his Percocet." It seems to me that he was awake enough to talk to the doctor, so could this be used as the history caveat? I am leanings towards no, but I just wanted some other opinions. Thanks!
 
lilleyea said:
I know this is an old thread, but what if the patient is sleeping? The doctor put "Pt sleeping at the time of examination and contributed only LE edema and Low back pain to me. More worried about getting his Percocet." It seems to me that he was awake enough to talk to the doctor, so could this be used as the history caveat? I am leanings towards no, but I just wanted some other opinions. Thanks!
Click to expand...

No if the patient can be awaken, it doesn't qualify.
 
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