# Review of Systems - exception of this line



## ammontagano (Feb 2, 2009)

Below is what one of our docs uses for his Review of Systems for a new patient.  He believes by using this he can bill out a 99203--all other aspects of his notes substantiates a 99203 with the exception of this line.  Our coders here feel that he needs to add "pertinent negatives and positives" to the note in regards to the ROS.  Any thoughts?

I did review his review of systems, past, family, and social history. This has been scanned into the chart.

Thanks
Ann Marie


----------



## kbartrom (Feb 2, 2009)

*Ros*

From CMS 1995 DOCUMENTATION GUIDELINES FOR EVALUATION & MANAGEMENT SERVICES

A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI.

_!DG: The patient's positive responses and pertinent negatives for the system
related to the problem should be documented._

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems.
_
!DG: The patient's positive responses and pertinent negatives for two to nine
systems should be documented._

A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

_!DG: At least ten organ systems must be reviewed. 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._


----------



## FTessaBartels (Feb 2, 2009)

*Depends on the what he is referring to*

The physician should be referring to a specific document, by type and date (Example:"I reviewed the patient history questionaired dated 1-19-09 today ...")

Second: The physician should sign and date the document s/he reviewed (or at least initial & date). 

Third: Ideally the physician will specify pertinent positives and negatives. 

However, if the questionaire the physician refers to is complete (including details of positives), then I'd give credit for the ROS. 

Remember - for 99203 you only need 2 systems, and any one of the past, family or social history. 

F Tessa Bartels, CPC, CEMC


----------



## Love Coding! (Feb 2, 2009)

*Shave removals sent for pathology*

Hi all,

I read in last month's coding edge regarding the different types of removals Shave (11300-11313), Biopsy (11100, 11101) and Excisions (11400-11446), 
(11600-11646), (17260-17285)

So what I got out of it was that if we are sending something for pathology you use the 11100, 11101, etc. codes.

Can you really not use the 11300-11313 to bill for biopsy with a shave technique?

If that's the case would it be fair to say, that you CAN bill a 11100 for a biopsy stating that it was done with a shave technique?  


I hope that I made sense,

Thanks, dscoder74


----------



## Love Coding! (Feb 2, 2009)

*Please disregard last entry*

I was in the wrong topic...:0)


----------

