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sla696

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A question has come up related to 95 DG regarding ROS. A provider states in note dated 8/10/09, "ROS are unchanged from previous visit. Details of this historical information is in the transcription of 8/3/09."

The note from 8/3/09 gives 2 pertinent negative ROS. All other elements of history (HPI and PFSH) meet 99214. I am disagreeing with colleagues that the statement above does not meet an extended (detailed) ROS based on the other DG requiring 2 or more pertinent positive/negative ROS was documented for this visit (8/10). Am I completely off base? Thoughts??

Thanks
 
The one problem I have seen with this method is that some ROS' have changed from the last visit and the current documentation leads you to believe it was reviewed. I see this, sometimes, with copying and pasting from the last visit. However....if the documenation supports 4 elements of HPI, 2 ROS, and 1 PFSH...then you have met a detailed history.

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 or
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:
• describing any new ROS and/or PFSH information or noting there
has been no change in the information; and
• noting the date and location of the earlier ROS and/or PFSH.
 
Since the note from 8-3 provides 2 ROS and the providers documentation acknowledges that he reviewed 8-3's entries and notated that nothing has changed...I would credit the ROS as extended. The 95 DG's state.."the patient's positive responses and pertinent negatives for two to nine systems should be documented" for an extended ROS.
 
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