# ROS negative except as documented in HPI question



## calorom2 (Jan 25, 2019)

I would appreciate any thoughts on this as there isn't agreement in my office. Would this be acceptable documentation for a 10pt ROS?

Thank you?

Review of Systems Constitutional:  Negative except as documented in history of present illness.  
Eye:  Negative.  
Ear/Nose/Mouth/Throat:  Negative.  
Respiratory:  Negative except as documented in history of present illness.  
Cardiovascular:  Negative except as documented in history of present illness.  
Gastrointestinal:  Negative.  
Genitourinary:  Negative.  
Musculoskeletal:  Negative.  
Neurologic:  Negative.  
Psychiatric:  Negative.


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## calorom2 (Jan 25, 2019)

Any one have any thoughts on this?


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## Mayzoo (Jan 25, 2019)

I believe that would acceptable.  Here are a few links to review.


https://www.aapc.com/memberarea/forums/51215-ros-systems-negative.html

And many others...I just looked this up a few days ago, so I had the links handy.


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## Pathos (Jan 29, 2019)

I commonly refer to the CMS guidelines whenever there is a question regarding E/M documentation.

The guidelines explain:
"_Those systems with positive or pertinent *negative *responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented._"

The example you are giving, seems acceptable. However, as with most E/M documentation, always check with the patient's payer for any specific E/M policies/guidelines.


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