E/M Coding:
Reasons Your Review of Systems Documentation Could Be Sabotaging Your Claims
Published on Wed Sep 19, 2012
Is "All Other Systems Negative" a ticking time bomb, set to explode your ROS cred?If you're relying too heavily on the handy phrase "all other systems negative" in documenting a complete Review of Systems (ROS), you could be setting yourself up for an audit feeding frenzy. The basics: ROS is a crucial element in supporting a 99285 E/M service; CMS E/M Guidelines indicate that documenting pertinent positive and negative findings combined with the statement "all other systems are negative" will be considered a complete Review of Systems. This phrase can be beneficial to allow physicians a shortcut in the documentation process.Caveat: Physicians should realize the gravity of documenting "all other systems negative", warns Todd Thomas CPC, CCS-P, President of ERcoder, Inc. in Edmond, OK. "All other systems negative" is often interpreted to mean that the physician has performed a review of all fourteen systems, and other than the systems documented [...]