review of systems

  1. B

    Wiki Dx Coding and ROS

    Can a diagnosis code be pulled solely from the review of systems alone? I was recently dinged on an audit for a dx code the auditor believes I should have added. The code in question is R39.11 for urinary hesitancy, only mention of urinary hesitancy within the note was in the ROS. It is my...
  2. Z

    Wiki ROS Confusion

    Can a Review of Systems be counted as complete if it appears as the following on a note: Review of Systems Below systems reviewed with the patient's wife, all are negative except as noted above General ROS Allergy and Immunology ROS Hematological and Lymphatic ROS Endocrine ROS Respiratory ROS...
  3. M

    Wiki Necessities for inpatient initial consult

    When coding for 99221-99223, I have seen mixed reviews on what is acceptable for a complete ROS, some state that if you document the positive systems with associated symptoms, and write "all other systems reviewed and negative" it is acceptable for a 99222 or 99223 (with all other requirements...
    • MWoessner
    • Thread
    • 99221-99223 e/m documentation inpatient consultations review of systems
    • Replies: 3
    • Forum: E/M
  4. P

    Wiki Review of Systems audit perfection

    I am the Medical Director of a surgical group practice. We recently started using a new auditor for our medical records. The new auditors keep excluding our Review of Systems as invalid because they might not exactly match the rest of the medical record. I have argued that the review of...
  5. F

    Wiki Review of Systems

    Please help! One of the physicians in our practice routinely uses this statement when making an initial hospital visit or consult: "Review of systems: Reviewed. The patient's review of systems found on the patient's chart under physician documentation is noncontributory." How could that even...
    • fltbaroque
    • Thread
    • auditing e/m review of systems
    • Replies: 2
    • Forum: E/M
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