Cpolisena
Contributor
What to do when an H&P, Consult, ER note etc. have the 'Review of Systems' documented as 'Unobtainable'?
I've read mixed opinions from other coders & CMS publications. I am not one single bit sure I have an answer that I feel comfortable with. Especially when the ROS is what my code of choice is going to rely on since the rest of the note is documented properly. So we could be talking about selecting a 99223 or a 99221 for an admit or even a 99255 or 99252 for IP Consult, again, depending on the definition of a 'Unobtainable' ROS. That's a lot of $ riding on the choice of codes!
I've read both the 1995 & 1997 CMS E-M Documentation Guidelines and nothing is clear cut! Which I should have probably expected in the world of coding
Can anyone help with something more substantial to stand on, a document or something in writing would be awesome!
Thank you
I've read mixed opinions from other coders & CMS publications. I am not one single bit sure I have an answer that I feel comfortable with. Especially when the ROS is what my code of choice is going to rely on since the rest of the note is documented properly. So we could be talking about selecting a 99223 or a 99221 for an admit or even a 99255 or 99252 for IP Consult, again, depending on the definition of a 'Unobtainable' ROS. That's a lot of $ riding on the choice of codes!
I've read both the 1995 & 1997 CMS E-M Documentation Guidelines and nothing is clear cut! Which I should have probably expected in the world of coding
Can anyone help with something more substantial to stand on, a document or something in writing would be awesome!
Thank you