# Review of Systems - brought study guide



## Naveen Rachagolla (Nov 20, 2012)

Hi, Iam preparing for CEMC, and i brought study guide from AAPC, in page # 18 under ROS it states that..

ROS should be medically necessary. It may be considered necessary to obtain a complete ROS when patient present as an initial new patient. It may not be considered medically necessayt to repeat that complete review on every follow up.

And my Question is..


If patient comes as a follow up and the physician has already done complete ROS and PFSH in the initial visit, can the physician again take the ROS and the PFSH form the initial medical record ? And what if physician dint do any ROS or PFSH in the follow up visit.


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## onetwothree (Nov 20, 2012)

No, he can't take from the previous ROS or PFSH, look at the established patient in cpt book, doc has to fulfil all the necessary examination to decide the level for visit.


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## MikeEnos (Nov 20, 2012)

Naveen,
It is true that the provider can only bill for the highest _medically necessary_ level of History and Exam.  However, if your provider documented a complete ROS and PFSH (or had the patient or ancillary staff provide this info, and the provider reviewed/signed/dated it) they can refer to it in their follow-up visit.  For example, the might list pertinent positive and negative systems reviewed today and say the remainder of the ROS is unchanged from the previous visit on 10/15, as well as the PFSH - or they could say all other systems are reviewed and negative.  The provider should again initial and date the previous form (if it was a paper form supplied by the patient or ancillary staff).  They SHOULD NOT use this phrase, only to have you go to that chart and see that it references another date.  

Keep in mind that though this will help you calculate the level of History and Exam, it has to be medically necessary.  Theoretically every provider could document a comprehensive history and a comprehensive exam, but that wouldn't be medically necessary so you wouldn't say they are all 99215's (even though 99215 only requires 2/3 key components, and you technically meet those requirements.)  I'm not a clinician, so I usually defer to the clinical judgement of my doctors but I make sure they are aware that they medical necessity should drive the level of code selection.

Sorry if that was a bit long-winded.  If I ended up giving you more questions than answers, I apologize! Best of luck to you on obtaining your CEMC certification, and have a Happy Thanksgiving.


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## RebeccaWoodward* (Nov 20, 2012)

To add to Mike's reply...(good advice I might add)

❖ A ROS and/or a PFSH obtained during an earlier encounter does not need to be rerecorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an
institutional setting or group practice where many physicians use a common record.

The review and update may be documented by:
• Describing any new ROS and/or PFSH information or noting there has been
no change in the information; and
• Noting the date and location of the earlier ROS and/or PFSH.

❖ The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by
the patient. To document that the physician reviewed the information, there must be
a notation supplementing or confirming the information recorded by others.

Page 14...

https://www.cms.gov/Outreach-and-Ed.../downloads/eval_mgmt_serv_guide-ICN006764.pdf


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## Naveen Rachagolla (Nov 21, 2012)

RebeccaWoodward* said:


> To add to Mike's reply...(good advice I might add)
> 
> ❖ A ROS and/or a PFSH obtained during an earlier encounter does not need to be rerecorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an
> institutional setting or group practice where many physicians use a common record.
> ...



Thanks Folks for your time in explaining the logics behind the play,

But my concern is that if the physician is documenting the ROS and PFSH FOR the F/U visit stating that reviewed and no change, in this case DOES THE PHYSICIAN GET CREDIT FOR THE ROS AND PFSH EVEN THOUGH HE GOT FULL CREDIT FOR ROS AND PFSH IN THE INITIAL VISIT ?


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## RebeccaWoodward* (Nov 21, 2012)

Assuming he/she has proper documentation and it is relevant and medically necessary, yes.  This is one of those areas that you have to apply good judgement.  You have to examine the entire note and determine if the reason for the visit, exam and assessment supports a complete ROS/PFSH. Often times, it is obvious whether or not this information supports the visit.  If *I'm * uncertain, I will audit the record with and without the information (or the minimal information needed for that particular visit).  If I score two different levels, I will add my thoughts to the audit and have a discussion with the provider when it's time to meet.  Then I can get some feedback from the provider as to why he/she does or does not agree with me.  This is a time for both of us to provide feedback and have our opinions heard.


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## MikeEnos (Nov 21, 2012)

Right, again I agree with Rebecca - you will want to make it a point of discussion so that you can make sure the provider understands (rather than 1 sentence on a report.)  

Remember, if the provider is referencing the ROS or PFSH from the previous visit that they already got credit for, that's fine, but if it's a paper chart they should date and initial the form again to verify that they reviewed it and the patient agreed it was unchanged.   Also - in the even of an ACTUAL audit by a RAC or from an insurance company, does the person in Medical Records know to include that form from a previous date with the chart for that date??  If not, the provider will not get credit for the complete ROS.  That's another thing to consider when providers reference information that was recorded in a previous note.


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## Naveen Rachagolla (Nov 21, 2012)

Once again thank you Mike and Rebecca for your contribution, and i hope you wont mind it or bored off if i dragg this to some more extent or in future.

Mike can you just detail this *Also - in the even of an ACTUAL audit by a RAC or from an insurance company, does the person in Medical Records know to include that form from a previous date with the chart for that date??* 

The one which is underlined.


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## MikeEnos (Nov 26, 2012)

Sure - let's say you get a request for a record as part of an audit.  The request is for the note for DOS 8/15/2012 which was billed as a 99215.  They need that documentation within 30 days.  You ask the person in Medical Records to gather the info and mail/fax it in- and you think you're all set.  However,  if that note doesn't have a ROS, or PFSH, but instead says "the Review of Systems, Past Medical, Family, and Social History is reviewed with the patient and is unchanged from the last visit on 7/10" but that 7/10 note is not included, the auditor will not give you credit for those elements.  That could result in a failure of the audit, and possible recoupment of payments that were made. 

It is critical that if you are using that phrase, the person responsible for responding to the records requests knows they have to include not only the note for the DOS requested, but also any related documentation.  It isn't acceptable to send the entire patient's record (due to HIPAA you have to include only the minimum necessary information) and have them select what they need.


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## Naveen Rachagolla (Jan 8, 2013)

*ROS and PFSH*

Hello Mike and Rebecca,

As we discussed a lot on ROS and PFSH previously,

Incase if the patient comes for follow up and the Doc or the physician dint mention anything about the ROS or the PFSH in the current note, as a coder can we go ahead and code as per the current available note or can we take the ROS or the PFSH from the initial note, Because if we look at family history, most of the times it will be same for all the follow up visits compared to initial visits.


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## RebeccaWoodward* (Jan 8, 2013)

Naveen Rachagolla said:


> Hello Mike and Rebecca,
> 
> As we discussed a lot on ROS and PFSH previously,
> 
> Incase if the patient comes for follow up and the Doc or the physician dint mention anything about the ROS or the PFSH in the current note, as a coder can we go ahead and code as per the current available note or can we take the ROS or the PFSH from the initial note, Because if we look at family history, most of the times it will be same for all the follow up visits compared to initial visits.



The provider needs to reference the previous ROS/PFSH by dating/signing the previous recorded information.  Simply pulling the information from a previous visit, without proper documentation, will nullify this information.  Word of caution:  When referring to previously recorded information (ROS/PFSH), make sure the original/updated date of service is recorded.   I have found that some providers will make a "blanket" statement that they have reviewed the previous ROS/PFSH only to find that the date of service they referenced is not consistent with the original/updated information. When I pulled the date of service they referenced, the same "blanket" statement was recorded.  The actual ROS/PFSH that was originally recorded/updated was linked to an entirely different date of service.


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## Lynda Wetter (Jan 8, 2013)

Correct me if I'm wrong but I was taught youcan not as a coder refer to documentation from a previous visit UNLESS the doctor refers to it by date and signs it.
You code for the "note" you have in front of you, everything has to be linked in order for you to be able to refer to it. If the Doctor does not link it by referring to it in the current note by date then you can not refer back on it yourself.

Lynda, CPC


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## RebeccaWoodward* (Jan 8, 2013)

AlwaysSunny said:


> Correct me if I'm wrong but I was taught youcan not as a coder refer to documentation from a previous visit UNLESS the doctor refers to it by date and signs it.
> You code for the "note" you have in front of you, everything has to be linked in order for you to be able to refer to it. If the Doctor does not link it by referring to it in the current note by date then you can not refer back on it yourself.
> 
> Lynda, CPC



Is this not what we have been advocating in this thread?


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## Lynda Wetter (Jan 8, 2013)

RebeccaWoodward* said:


> Is this not what we have been advocating in this thread?



YES, this is what has been discussed in this thread...
I just did not see your post responding to the question regarding using previous documentation.


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## Naveen Rachagolla (Jan 9, 2013)

Thank you, Rebecca and Lynda for your thoughts.


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## bellboy (Dec 12, 2018)

So, if the note has the following:  pertinent positive and negative systems reviewed today and say the remainder of the ROS is unchanged from the previous visit on 10/15, as well as the PFSH - or they could say all other systems are reviewed and negative. The provider should again initial and date the previous form (if it was a paper form supplied by the patient or ancillary staff). Would the ROS be Problem Focused, Expanded Problem Focused, Detained or Comprehensive?  Thanks


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