ED Coding and Reimbursement Alert

Here's how to handle ROS black holes - and avoid federal scrutiny

There's no question that when the ED physician checks the "all others negative" box for ROS elements, you can be left with less information than you'd like. Here's the skinny on when you need more specific data and when you can let your doctor slide.

Require the Basics

If your doctors resist supplying more information when they've checked the "all others negative" box, keep your eyes peeled: the systems the physician considers for the review of systems (ROS) elements can be hidden in the history of present illness (HPI) elements.

There are no numerical requirements for how many systems the physician must document in conjunction with the "all others negative" statement, and it is up to the doctor to decide how many systems are pertinent to the complaint.

The documentation guidelines simply say "positive or pertinent negative responses." If the physician indicated positive or negative for at least one system and checked the "all others negative" box, then he has documented a complete ROS.

Hidden trap: While the decision about ROS is ultimately the physician's, he shouldn't consider checking the "all others negative" box a complete ROS when he hasn't evaluated any other systems. Without documentation of positive or negative responses to at least one system, the "all others negative" statement has no value.

You can also have a problem if a physician has a consistent pattern of checking the "all others negative" box with no variation in the ROS documentation, says Rebecca Pate, RN, CPC, with Central Kansas Coding Specialists.

"This could be a red flag to auditors, so you should encourage your practice not to rely solely on the 'all others negative' box," Pate says. In the end, the auditors may be uncomfortable if all the charts look the same, particularly if they all have the ROS box checked. "The medical necessity for a complete ROS for patients with minor complaints just isn't there," she says.

Adopt a Practice Policy

While there are no numerical requirements for the number of systems with "all others negative" - or guidelines on which situations warrant it - a helpful rule of thumb is to have a practice policy of always documenting review of two systems in addition to checking the "all others negative" box.

If you need two-nine body systems for an extended ROS, and the requirements for a complete ROS state that you need documentation for "all additional body systems related to the problem," it is reasonable to require documentation of two or more systems with the "all others negative" box, says Kevin Arnold, CPC, outpatient coder at Danbury Hospital in Danbury, Conn.

For example, a patient with chest pain as a chief complaint presents in the ED. In the HPI, the description of the chest pain is the only "system" the physician addresses, including documentation of severity, quality, etc. The physician doesn't mention shortness of breath, diaphoresis, or anything related. But under a policy requiring documentation of two systems, the physician would have had to review and record at least one more system.

Because any history requires a chief complaint, having documentation of additional systems makes sense, says Debbie Hayes, RN, CPC, director of compliance, auditing, and training for Medical Services Billing Technologies.

Stem Overuse With Common Sense

When deciding whether to ask the physician about the ROS documentation, check to see that the number of systems makes sense with the patient's problem. If a physician is always checking the "all others negative" box to imply a complete ROS - even if he documents individual review of two additional systems - make sure that the presenting problems warrant review of 10 or more systems. 

If not, and the physician has succumbed to checking the "all others negative" box as a default, you could be asking for trouble with auditors. If record upon record shows a complete ROS that is clinically unnecessary, an auditor could suspect that you're using the documentation shortcut as a way to beef up your evaluation and management levels.