We recently began coding for pediatrics, both in-patient and out-patient. We have a question regarding the History portion, specifically the ROS as to what would be acceptable documentation for the neonate patient.
Would it be sufficient if the provider added a note stating something to the effect that the ROS is unobtainable due to patient's age, or possibly use positive ROS from the birth history (in the case of a neonate) - then state something like "other than what is found in HPI, the ROS is negative for this neonate on first day of life"?
Our pediatricians are seeing the neonate patient's at the hospital and also in the clinic. For this age patient, it is challenging as how to obtain a detailed or comp ROS. Is there a statement that can be used, similar to using "patient obtunded" or "unattainable due to ____"?
We considered basing these visits on time as the NICU providers do, but want to be sure that is a viable option, using the counseling and/or coordination of care for all of these types of patients.
These are complex visits, but with documentation requirements make it difficult to meet the level they should be billed at.
Thank you for any help you can give.
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