# Ros -physician documents



## krssy70 (Feb 17, 2010)

If a physician documents that he did a 10 point review of systems, otherwise negative...... and did not document which ROS he reviewed.  Would you count a complete ROS?  I don't think so, but would like some feedback.

Thanks, 
Kristen


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## Lisa Bledsoe (Feb 17, 2010)

I wouldn't count it.  There has to be some pertinent positives/negatives noted prior to using the freebie statement (that's what I call it).  Also, since there are 14 systems, we need to know which 10 are reviewed...


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## LTibbetts (Feb 18, 2010)

Lisa (or anyone else for that matter), I am not sure if you can help me with this but I have a provider here that does that same thing on all of his ER t-sheets in the ROS section and he is driving me crazy. I was told by someone in this forum a while back that if there is no ROS other than the box being checked for the _all systems reviewed, otherwise negative_, that we could use some of the symptoms in the HPI section if needed (ex: if 10 things are reviewed in HPI, use 3-4 for the HPI and the rest for the ROS). Is that true, or did I misunderstand?


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## LindaEV (Feb 18, 2010)

If they are coming in for a problem...say chest pain, which is described in the HPI...isn"t it assumed that you can count this for ROS without having to redocument? So...if he then later, under a heading of "ROS", checks only a box that says "all systems reviewed, otherwise negative", he'd get full credit??
I have a letter on CMS letterhead that says you do not have to document twice for the same system in HPI and ROS, that if the documentation is good, it is easily inferred that this sytem was reviewed.
Seems logical to me...but I'd love to hear others thoughts on this.
http://www.donself.com/documents/HPI.pdf


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## krssy70 (Feb 18, 2010)

I have always been told that counting a system within the HPI and also in the ROS is considered to be double dipping. I had posted a question a while back that questioned that exact same thing, and the answer that I got was counting an element in the HPI, for ex: Abdominal Pain, and then counting it as the Gastrointestinal system reveiwed in ROS, without documentation stating GI: Negative/Postive, is double dipping. I myself do not count it twice. If I count it in the HPI, then I do not count it in ROS, unless it is documented twice. 

As for the ROS (evil box). I do not utilize the T-system, so my physicians dictate and it is transcribed into a typed dictation. My initial question would construde as the same as the "evil box". The physician dictates ex: ROS: 10 systems reveiwed, otherwise negative.... Why cant that be counted the same as the "evil box"?


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## LTibbetts (Feb 18, 2010)

I am inclined to agree, Kristen, which is why the confusion I do think that it would be considered double dipping. I will read over that CMS document anyway and see what it has to say, but when it comes to E&M, I want to know about what multiple carriers think, not always just medicare, you know? I was taught to follow the audit tools but I also have been doing a lot of E&M training and I just can't seem to find difinitive answers on some of this stuff and I am finding that some of it is open to interpretation by different carriers and different coders. 

I don't see why I couldn't use 3 elements of the HPI for the actual HPI and the rest of the elements covered in the HPI for the ROS. It wouldn't be double dipping, as each one is only being used once, right? I can't seem to find anything in writing that says that I can't do it that way. The person in this forum that told me that I can do that is someone that I respect, admire and trust very much and I am inclined to just go with her on faith. I just wanted to get others' opinions on it.


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## krssy70 (Feb 18, 2010)

LTibbetts said:


> I am inclined to agree, Kristen, which is why the confusion I do think that it would be considered double dipping. I will read over that CMS document anyway and see what it has to say, but when it comes to E&M, I want to know about what multiple carriers think, not always just medicare, you know? I was taught to follow the audit tools but I also have been doing a lot of E&M training and I just can't seem to find difinitive answers on some of this stuff and I am finding that some of it is open to interpretation by different carriers and different coders.
> 
> I don't see why I couldn't use 3 elements of the HPI for the actual HPI and the rest of the elements covered in the HPI for the ROS. It wouldn't be double dipping, as each one is only being used once, right? I can't seem to find anything in writing that says that I can't do it that way. The person in this forum that told me that I can do that is someone that I respect, admire and trust very much and I am inclined to just go with her on faith. I just wanted to get others' opinions on it.




That is correct. If I dont count it in the HPI, then most definetly, I will count it in the ROS. The only thing that I was stating is that if I do count it in the HPI, then unless it is documented twice, then you cannot count it. Its just so confusing, because you have 2 different out looks on the issue, and it makes it so your not sure. My initial question has kinda turned into a different question, which is ok, I like to get all kinds of feedback from fellow coders out there. As for the CMS guidelines, they are not specific to the ROS. So its hard to come up with a plan and stick to it. I appreciate your feedback, and would appreciate if you could send me anything you may find reg this issue. Thank you so much.


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## FTessaBartels (Feb 18, 2010)

*HPI vs ROS*

The fact that different carriers have different "rules" doesn't help this at all! (e.g. some do *not* allow the "all others reviewed and negative" statement AT ALL).

HPI vs ROS ... a lot of providers lump everything in history into one big paragraph when they document.  

For illustration purposes let's all assume for a minute that we have a NEW patiient.

You have to have 4+ HPI elements in order to get to the comprehensive or detailed history.  Let's pretend that you have an HPI that read:
Patient has had vascular malformation at the right axila since birth; large maroon-colored lesion is 3cm x 5cm and has been growing over last six months. Occasional pain and swelling of RUE, particularly after exercise. Had previous sclerotherapy in 2007 with minimal improvement; but lesion has grown back. Patient thinks it is now worse than it was before. 

You have more than 4 elements here. You can stop counting when you get to 4.   IF you need more info for your ROS or past medical history you can take it from the parts of the above paragraph you didn't count as HPI. (e.g. pain and swelling could be counted as associated symptom, *or* used as ROS  // sclerotherapy could be counted as a modifiying factor for HPI *or* could be counted as past medical history)

Let's move on to ROS.  The defnition of "double dipping" is somewhat nebulous. The most conservative would be that you can *not* count the same *system* in your ROS as in your HPI. So - for example -  if your complaint is vomiting you can not count GI at all in ROS.  

Another interpretation is that you can count the same system, but not the exact same verbage.  So if you have a complaint of vomiting, and your HPI mentions nausea and vomiting for 3 days  you would need some *other *item applicable to the GI system to count for ROS (for example: tenderness, masses, constipation, diarrhea, etc). 

The most liberal interpretation is that you *can *count it if it is actually *stated* multiple times.  So you could have: chief complaint vomiting / HPI vomited twice this morning; had nausea for past 3 days without fever or abdominal tenderness / ROS: GI: vomiting and nausea.

Now back to the original post which was can you give credit for the statement "10 systems reviewed and negative."  I say "no" - because there are 14 systems and this statement doesn't tell me WHICH of the systems the provider reviewed.  Best to list them all individually -or- (if your provider allows) list the pertinent positive/negatives and state "all other systems reviewed and are negative."  (Of course, you have to have *actually reviewed *all the systems.)

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## krssy70 (Feb 18, 2010)

Thank you F Tessa. I really appreciate you taking the time to respond. This has always been a question for me, never really sure how to treat that statement. Thank you so much for clearing that up for. Have a wonderful day 

Kristen


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## LTibbetts (Feb 19, 2010)

Tessa, that does help clear up Kristens problem with the 10 systems reviewed question and it explains a lot for me as well about the different documentation, but in the matter of us using the t-system where I work, the box located in our ROS box simply states "all systems negative except those as marked" and they are checking this with nothing else whatsoever marked in the box. This is the case where I would like to use the leftover HPI elements for use in the ROS section, and am unsure. I believe that this is how it was initially explained to me, but I just want to make sure. We are having many dilemnas over this t-system and I would just like to have some back up for my case for future arguments, if possible.


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## cfullum (Feb 19, 2010)

*Ros*

If you have ROS in the HPI you can use that for ROS, also, the rules for double dipping have changed. You are now allowed to double dip. If the physician states that 10 review of systems were reviewed and negative, that does not count you have to have at least one pertinent or negative ROS and the statement must say all other ROS were negative (or whatever his findings were).  The key words are "all other".  I hope this helps.


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## FTessaBartels (Feb 19, 2010)

*Responses*

cfullum writes: the rules for double dipping have changed. You are now allowed to double dip.   What?!  Please tell us where you saw that in writing because it is news to me. 

Leslie:  I am not familiar with the t-system you are referring to so I cannot answer your specific questions about that.  I would be tempted to NOT allow a blanket "all others negative except where marked" if NOTHING ELSE was marked. I mean SOMETHING has to be positive - why is the patient here? 

Sorry I can't be more specifc.  I gave it my best shot with my previous answer. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## dcgardrn@gmail.com (Feb 19, 2010)

The T-System is designed to include the system(s) pertinent to the chief complaint in the HPI. The HPI also contains other associated systems. This documentation may be counted for both elements within the HPI and the ROS. This is not double dipping. Dr. Barton C. McCann, the Executive Director of the Department of Health and Human Services, wrote in April of 1998 that "it is not necessary to mention an item of history twice in order to meet the Documentation Guidelines requirement for the ROS". A copy of this letter can be found on the American College of Emergency Physicians website (ACEP.org).

Regarding the "all systems negative except as marked box". Both the 1995 and 1997 Documentation Guidelines contain the following statement:

"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."

The "all systems negative except as marked" box is is not a performance shortcut. It is a documentation shortcut that is compliant with the CMS Documentation Guidelines. The "all" is the operative word. It should be marked only after the provider has performed a complete ROS and documented those systems with pertinent positives and negatives.

David Gardner, RN, CPHQ


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## Lisa Bledsoe (Feb 22, 2010)

FTessaBartels said:


> cfullum writes: the rules for double dipping have changed. You are now allowed to double dip.   What?!  Please tell us where you saw that in writing because it is news to me.
> 
> Leslie:  I am not familiar with the t-system you are referring to so I cannot answer your specific questions about that.  I would be tempted to NOT allow a blanket "all others negative except where marked" if NOTHING ELSE was marked. I mean SOMETHING has to be positive - why is the patient here?
> 
> ...



I am in complete agreement with what Tessa has said in this post.  If you have enough documentation in the HPI to crossover to the ROS (NOT DOUBLE DIPPING) then you can use those "extra" systems in the ROS to go along with the "all other" statement.  *Anyone who has Trailblazer as their carrier cannot use the "all other" statement*.  And to my knowledge, double dipping is *NEVER ALLOWED*.


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## LTibbetts (Feb 23, 2010)

Thanks Lisa and Tessa. That is basically what I needed to know. And Tessa, by the t-system, I only meant the t-sheets the providers use for ER visits. These have created _quite _a stir between the providers and HIM and I have brought this specific issue to them regarding the "all others negative" box without checking off anything else and all to no avail so this process of sharing the ROS and HPI notations (without double dipping) is what I needed to assure myself that I was still practicing properly according to the DG's, so thank again everyone


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## Viper66 (Feb 25, 2010)

I spent years using the T-System for an ER physicians group.  We always operated under the premise that the 'gimme box' was only valid IF pertinent +/- were marked in the ROS section (regardless of what was included in the HPI).  When our charts were audited by an outside auditing company, they supported our practice.


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## aguelfi (Mar 1, 2010)

I sent in a question about this to my local Medicare carrier, First Coast (FL). The specific question was:
What is the acceptable verbage for documenting the remaining ROS that were checked but negative?
Answer: All other systems negative.

There is no mention that the number of systems reviewed has to be mentioned.


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## coder25 (Mar 4, 2010)

abenson said:


> I sent in a question about this to my local Medicare carrier, First Coast (FL). The specific question was:
> What is the acceptable verbage for documenting the remaining ROS that were checked but negative?
> Answer: All other systems negative.
> 
> There is no mention that the number of systems reviewed has to be mentioned.




I, too, asked the representative at an E/M conference sponsered by Highmark Medicare (Pennsylvania).  They also said that it is was totally acceptable to mention positive ROS with the remainder of the 10-point ROS being negative.  They also stated that I could use items from the HPI for my ROS and that they do not consider this double dipping.  This last sentence is actually printed in the booklet that they gave out at the conference.

Peggy


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