General Surgery Coding Alert

Question: One of our surgeons tends to note “all others negative” in the electronic health record for his review of systems (ROS) part of the exam. Can we count this when we’re choosing the appropriate E/M code?

Codify Subscriber

Answer: You may be able to find ROS elements in the history of present illness (HPI), but keep in mind that the physician must document at least one problem pertinent system with the “all others negative” statement. It’s actually up to the doctor to decide how many systems are pertinent to the complaint.

Because the documentation guidelines 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.

You need that one system: 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. This isbecause auditors may be uncomfortable if all the charts look the same, particularly if they all have the ROS box checked.

Remember that there still has to be medical necessity for obtaining all the review of systems. If a patient presents with an injury to her arm and three or four ROS are marked (such as respiratory, cardiac, ENT, or abdominal), an auditor may call medical necessity into question or request additional documentation to support why these ROS were medically necessary.