Otolaryngology Coding Alert

Question: An internal audit found that the otolaryngologist's documented review of systems (ROS) sometimes contradicted the history of present illness (HPI). What could be causing this mismatch?

Georgia Subscriber

Answer: Templates could likely be the cause of the contradiction. Stress the importance to your physicians of paying attention to the boxes they check on the ROS form. Hurriedly marking boxes can lead to mismatches, such as an HPI that indicates sore throat and runny nose and an ENT ROS box marked "negative."

Also remember when using ROS forms that the provider should include a remark that the medical history and ROS are documented on another form.

The otolaryngologist should also address any abnormal or pertinent negative findings in the note.

Tip: Check if your electronic medical record (EMR) system can alert the physician to inconsistent histories.