ED Coding and Reimbursement Alert

Question: Encounter notes indicate a patient presented to the ED following a collapse and blackout; the patient had reported having chest pain 5 minutes before the blackout. During the review of systems (ROS), the physician gets positive responses when she asks the patient about head pain, dizziness, chest pain, muscle pain, and breathing trouble. The patient also had several nicks and cuts incurred from the fall that the physician asked about. Then, the physician wrote "Review of all other systems negative." Does this qualify for a complete ROS?Missouri SubscriberAnswer: You should be able to report a complete ROS -- though you are best served to include more specific documentation about the positive ROS checks.Do this: Make sure that you have proof of the patient's positive ROS responses in the documentation: neurologic (head pain, dizziness) cardiovascular (chest pain) musculoskeletal (muscle pain) integumentary (cuts and bruises) respiratory (breathing trouble).And then: You can use [...]