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samyjm13

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I have a provider that does not put in ROS's, I don't feel like I can code her to the highest level of specificity. The HPI can be a 3 and exam can be a 3, but MDM is low and without ROS's, I feel like I am not coding the right E/M.

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samy
 
If your doctor is giving you enough of a narrative in the HPI story from the patient you may be able to pull some of the ROS out from that.

If you are using an EMR perhaps you can create a macro that is a reminder that the ROS needs to be there.

Reminder the ROS can be collected by staff so if they are asking the questions and adding it, that can be counted as long as the doctor mentions he/she reviewed it.

If it is a new patient and you are in the habit of having the patient fill out a questionnaire that has the the questions like "are you or are you now having.....headaches, bleeding ulcers, blood in urine...etc?" This could be scanned into record and counted as the ROS too.

I hope the suggestions help....Janell
 
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