Wiki Unattainable ROS

[pheeprice]

Can anyone tell me what level to assign for ROS when the patient is unable to provide the information? i.e. problem pertinent, extended, or complete? Thank you for the help.

 

[Lisa Bledsoe]

You can get a complete ROS if your provider documents that the patient was unable to provide it and why.

 

[pheeprice]

Thank you

Thanks a lot, that really helped.

 

[cpccoder2008]

ER

We had a patient come through the ER with an overdose, doctors put "unable to get a complete ROS due to patient being sedated and intubated from overdose " I gave a complete ros for this, Is that correct ?

 

[Lisa Bledsoe]

We had a patient come through the ER with an overdose, doctors put "unable to get a complete ROS due to patient being sedated and intubated from overdose " I gave a complete ros for this, Is that correct ?

Absolutely! As long as it is documented as to why the ROS could not be obtained.

 

[LLovett]

Depends on the carrier

WPSMedicare will not allow this. You only get credit for what you actually document, regardless of the reason why you couldn't get it.

Remember ROS doesn't have to come from the patient, if there is another history source (ie family) you can get the history from them.

Laura, CPC, CPMA, CEMC

 

[dballard2004]

The E/M guidelines do not state that the provider gets credit for a comprehensive history if they are unable to obtain a history from the patient. The guidelines just say that the provider has to state why he/she can't obtain the history. What happens beyond that point falls to the carrier. I would recommend in this case you consult with your carrier to see what their recommendation is.