Wiki 2021 E&M Guidelines for ROS for New patients

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wynonna

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A lengthy, time consuming Review of Systems questionnaire is filled out for all our new patients. It covers most or all body/organ systems.
It is time consuming for the patients to fill out and time consuming for the front desk to enter ROS info in the computer.
For ENT, is this very detailed form necessary for all new patients?
Or, can it be streamlined and made more brief since new guidelines focus on MDM and not ROS?
I understand Hx and ROS has to be medically appropriate.
Are there any rules or sources which address this? Or a ROS form specifically for ENT?
Any ideas what is the minimum documentation necessary to satisfy ROS guidelines?
thank you
 
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The primary reason the new guidelines were developed was precisely to eliminate the type of time-consuming and irrelevant information in documentation such as the comprehensive ROS that you are describing. There are no new requirements, to my knowledge, for any 'minimum documentation' of history or exam beyond that it be 'medically appropriate', as you've said. This language indicates to me that it is really up to the provider to make the determination as to what should be included since it requires a clinical training to understand what questions are appropriate to ask a particular patient given their presenting symptoms - something that is entirely outside the scope of coding. If your providers are asking for guidance on this, I might suggest having them do peer-to-peer reviews of each other's notes so that they can give each other feedback as to whether they feel they are capturing the medically essential information in the history and exam sections, since this no longer has a bearing on code choice - it is more of a clinical documentation quality question rather than a coding issue.

So to your original question as to whether or not this detailed form is necessary I would say you would need to turn to your providers for the answer. If the patients are filling out extensive information that isn't of use to your providers in evaluating the majority of problems that they treat, then they can and should revise this to save administrative costs and make it easier on everyone. There isn't a ROS that would apply to ENT across the board since the ROS is specific to the patient's problems and not the specialty, but your provider can consider the situations that they most commonly treat in their practice and create a form that captures the information that they consider most important for the majority of patients that they see on a daily basis and eliminates what they don't need.
 
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