Wiki ROS vs HPI

[CoderinJax]

Hello all,

I was hoping someone might be able to provide some clarification for me.

I have a Physician's note where the Dr copy/pastes all conditions he's previously treated the patient for in the header of the note, and in this case it's hx of spasticity and cervicalgia and cervical disc displacement.
The record states something along the lines of "Patient returns today noticing return of symptoms. The patient returns today stating the effects of the trigger point injection has completely worn off. She is in severe discomfort. The patient has noticed substantial reduction in severity and frequency of her symptoms. She is able to return to work and perform ADL's and is pleased overall. However the effects have worn off."

Would you all give credit for ROS-MSK when the physician states she is in severe discomfort? Or is that severity in the HPI? How many pieces of the HPI and ROS do you see in my note above?
I'm struggling with this record as it's extremely vague to me (what symptoms? What frequency were the issues before?) I'm giving Modifying factor credit for the trigger point since that seemed to work before for the patient.


Anyone have any advice on how I would measure this one from an E&M perspective?

 

[angbart80]

E/M

Hello all,

I was hoping someone might be able to provide some clarification for me.

I have a Physician's note where the Dr copy/pastes all conditions he's previously treated the patient for in the header of the note, and in this case it's hx of spasticity and cervicalgia and cervical disc displacement.
The record states something along the lines of "Patient returns today noticing return of symptoms. The patient returns today stating the effects of the trigger point injection has completely worn off. She is in severe discomfort. The patient has noticed substantial reduction in severity and frequency of her symptoms. She is able to return to work and perform ADL's and is pleased overall. However the effects have worn off."

Would you all give credit for ROS-MSK when the physician states she is in severe discomfort? Or is that severity in the HPI? How many pieces of the HPI and ROS do you see in my note above?
I'm struggling with this record as it's extremely vague to me (what symptoms? What frequency were the issues before?) I'm giving Modifying factor credit for the trigger point since that seemed to work before for the patient.


Wow, that is vague!!! This is what I copied from the 1995 CMS guidelines:

DG: The CC, ROS and PFSH may be listed as separate elements of history, or
they may be included in the description of the history of the present illness.

DG: A ROS and/or a PFSH obtained during an earlier encounter does not need
to be re-recorded if there is evidence that the physician reviewed and updated
the previous information. This may occur when a physician updates his/her own
record or in an institutional setting or group practice where many physicians use
a common record. The review and update may be documented by:
o describing any new ROS and/or PFSH information or noting there has been
no change in the information; and
o noting the date and location of the earlier ROS and/or PFSH.

DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form
completed by the patient. To document that the physician reviewed the
information, there must be a notation supplementing or confirming the
information recorded by others.

DG: If the physician is unable to obtain a history from the patient or other source,
the record should describe the patient's condition or other circumstance which
precludes obtaining a history.

That's a tough one, and I'd definitely look it over more than once and possibly ask the dr. for more clarification.

 

[CoderinJax]

super vague!

Tell me about it!
I've struggled all afternoon with how to give the MD credit for these sentences listed. I looked at 95/97 DG's, but I can't give credit to what's not truly there and I don't want to not give credit if some of the components ARE there and just aren't listed/documented the way I'd like.

So I was hoping to get a breakdown of "Yes, where the MD states "she is in severe discomfort" is ROS", etc. I feel like I'm pulling my hair out over here, lol...

 

[angbart80]

super vague

Tell me about it!
I've struggled all afternoon with how to give the MD credit for these sentences listed. I looked at 95/97 DG's, but I can't give credit to what's not truly there and I don't want to not give credit if some of the components ARE there and just aren't listed/documented the way I'd like.

So I was hoping to get a breakdown of "Yes, where the MD states "she is in severe discomfort" is ROS", etc. I feel like I'm pulling my hair out over here, lol...

I think I would only use it for one or the other. If I'm remembering correctly, you can only use it for one or the other... So you can use it for only ROS or only HPI. I only do emergency department coding, so I'm not an expert with the E/M for other places, like a dr's office, but I know for the ER, I'd use it only once, either for HPI or ROS, usually whichever one I needed more points in to get the highest level I could for that encounter. I'd have to see what the complete note said to properly code it as a certain level...

If I did it as an HPI, I would put it under the category of severity, if I put it under ROS I would place it under constitutional.

Here's a link that might help: https://emuniversity.com/ReviewofSystems.html

Hopefully that helps a little... I don't envy you having to code that, but I've been faced with the same because one of our former doctors we coded for was either documenting everything, I mean, everything, like the pt. came in with her boyfriend's mother because their car doesn't work and the boyfriend is at work so he couldn't bring the patient and the boyfriend's mother was sitting at home playing checkers, but stopped her game to bring her to the ER. I'm like, really...did I REALLY need to know all that? What does that have to do with the fact that she has a laceration on her finger? It was either over documenting like that or it was NOTHING... He was fun... NOT. He ended up getting a lot of lower e/m levels.

Hopefully your doctor's not like that. Would they be open to some education? Maybe you could send them a short email detailing what needs to be documented for a HPI, ROS, and MDM. (Or your boss, coding department manager, or whoever is in charge should actually do it.) Our doctors get an email pretty regularly just to remind them to keep up on it, because they all get tired? lazy? busy? and they don't do a good job every now and then. Then we remind them, they get better, then after a while they get worse and worse until we remind them again.

Good luck, and hopefully in the future you get all the documentation you need!

 

[CoderinJax]

Thank you!

Thanks so much for your help. I don't really have a way to reach the physician, since we audit for an outside group.

I do have a question though,that you might be able to help with under the "Amount and/or complexity of data to be reviewed" in the MDM.
The Dr also performs a urine toxicology test where he reviews the dipstick. Would you give him a point for ordering lab work as well as 2 points for reviewing the specimen himself?
Thanks again!!

 

[Pathos]

Thanks so much for your help. I don't really have a way to reach the physician, since we audit for an outside group.

I do have a question though,that you might be able to help with under the "Amount and/or complexity of data to be reviewed" in the MDM.
The Dr also performs a urine toxicology test where he reviews the dipstick. Would you give him a point for ordering lab work as well as 2 points for reviewing the specimen himself?
Thanks again!!

This is what CMS E/M guidelines say:

"DG: The review of lab, radiology and/or other diagnostic tests should be
documented. An entry in a progress note such as "WBC elevated" or "chest xray
unremarkable" is acceptable. Alternatively, the review may be documented
by initialing and dating the report containing the test results.

DG: The direct visualization and independent interpretation of an image, tracing,
or specimen previously or subsequently interpreted by another physician should
be documented."

To count both places for the same study would probably be considered double-dipping. If the provider did do the independent review (we ask our providers to include a brief summary), and documentation supports it, then he should be able to get 2 points for that review. If not, then probably 1 point for ordering the study, assuming documentation still supported the order and/or review of the lab.


Hope that helps!