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No you may not. The ROS is part of history and is information communicated from the patient, think of it as "do you have, or have you ever had..." whereas the physical exam is the physicans hands on exam and observations.
 
Ok...thank you for that info... that helps, although:

My issue is that my doc dictates his O.V. note. and he did not specify the ROS portion...He documented, HPI, PFSH, Medications, Allergies, and the Physical Exam. We are a breast Health center and this is a consultation for a patient that is being referred to us for a second opinion on her abnormal mammogram. The doc did an extensive HPI, extensive Physical Exam, has an assesment/Plan, extensive PFSHx, but No ROS...I would hate to downcode this chart due to all the extensive documentation and time spent with the patient...Please help...

Kristen, CPC
 
The ROS is information that can be collected by anyone or is a form the patient fills out. However you will need the physician to reference the ROS in his notes by noting the positive or any pertient negative issues. Or he can reference an earlier ROS as long as he indicates the date and location and that he has reviewed it with the patient to indicate no changes or yes changes. If there is absolutely no ROS then you will have a focused history and if this is a new patient you will have a very low level E&M, if it is establish patient then go with the exam and MDM for your level.
 
Ok, so If I have a extended HPI, Complete History area, and only an Detailed/Extended ROS utilizing the breast counted as 1 ROS, and the Vitals as 1 other Ros, which means I have 2 ROS, Can I still say that the HPI is comprehensive seeing as I have 2 out of the 3 elements in the HPI???
 
No HPI must be all three across the board and the lowest will determine the level of history. You visit level however, if this is a New patient is dependent on all three key components, History, exam, decision making, where established patient is 2 out of 3. IN your hisotry, if you have HPI that is extended, with no ROS and comprehensive PFSH then you have a focused history. Remeber there are actuall 4 components of HISTORY, that is :
chief compalint - must be stated or no history can be counted
HPI - to be extended must contain four elements of : location, quality, severity, modifying factors, associated signs and symptoms,etc...
ROS - which goes by body systems, 0 is focused, 1 is expanded, 2-9 is detailed, >9 is comprehensive
PFSH - which is patient medical hx, pertinent family hx, and social hx. 0 is focused, or expanded, 1 or 2 is detailed and 3 is comprehensive.
The vitals do not count as ROS, they are a part of exam. so it looks like you probably have a focused hx or an expanded focused at best.
 
I used to have a breast surgeon and she used time a lot for her coding. Something your provider may want to consider.

I know it doesn't seem right to get dropped because of ROS but that is the way it is unless you use time you have to meet all the required elements.

Laura, CPC, CEMC
 
This could be true, but the physician must document time spent with the patient as a part of the note and the counseling must be documented as well. Then maybe you could use time as the controlling component, but you need to be really diligent about the docuemntation when you do this.
 
So if the doctor documents all the time spent with the patient, and there still isn't any ROS...Can I assign the code that meets the time criteria?

Opposite senerio:
If I have a chart that meets the criteria for a level 4 o.v., and the doctor does document the time but is 5 minutes less than the time for a level 4 o.v., Can I still code a level 4?

Thanks for all your help girls....I am a little rusty on my E/M
 
If your doctor documents total time and % spent counseling and coordinating (which must be greater than 50% of the total time) you would bill the level supported by that, you don't count elements in this situation. It does have to be medically necessary though.

The opposite is true when you are talking about key components. It doesn't matter how much time is spent if the all the key components are there and support the level.

Laura, CPC, CEMC
 
Get a patient questionaire!

I concur with everything that Laura, Debra, et al have written about this.

Your physician is leaving a LOT of money on the table by not having a patient questionaire that the patient completes while waiting for her appointment. The complete ROS can be listed there and the physician only would have to review, sign, date and refer to it in his/her note.

You mention that this is a consultation referred for a second opinion. Okay ... you need to meet 3 of 3 elements for a consult - history, exam, MDM.

You mention that you have "allergies" noted ... you can use that as one element of ROS ... so you have at least a 99242. If you can find one more element of ROS somewhere in the history section of your note then you have a 99243. You would need to have 10+ systems ROS to get to a 99244.

If you can post a note it would be easier for us to help you identify what is what. Debra is absolutely correct that history & ROS are as reported by the patient while the exam is what is personally observed and recorded by the physician. But some physicians mix up their dictations and might say something in the middle of the exam like "she hasn't noticed any lumps, swelling or redness." That little phrase would be a report of what the patient reported NOT what the physician observed, and could therefore be counted in either HPI or ROS.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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