Does anyone have any documentation that Anthem accepts the above phrase? Per their E/M policy, it seems they require all 10 systems to be individually documented (at least that's the way I'm reading it). Here's part of their policy:
C. Review of Systems (ROS): The level of the ROS needs to be relative to the medical necessity of the presenting problem(s). For example:
It may be medically necessary to obtain a complete ROS when a patient presents as a new patient.
It may not be considered medically necessary to repeat a complete ROS on a follow-up visit.
If a provider uses a patient questionnaire to obtain information on the patient?s current signs and symptoms, the provider needs to acknowledge the review of the questionnaire as the source of the information, in the
office note, along with the provider?s signature and date on the questionnaire.
For new patient and consultation visits, the patient?s signs and symptom information (ROS) must be completely documented, including a description of each system that was reviewed during the encounter.
Established visits may use reference to a patient questionnaire. The ROS must be supported in the CC and
HPI. Documenting ?ROS negative? or ?ROS noncontributory? is not acceptable. The following
documentation is required, at a minimum:
Brief ROS documentation of positive/negative responses to problem pertinent systems directly related
to the chief complaint.
Extended ROS documentation of positive/negative responses for at least two to nine systems.
Complete ROS documentation of positive/negative responses for ten or more systems.
Any insight would be appreciated! Thanks-Sue
C. Review of Systems (ROS): The level of the ROS needs to be relative to the medical necessity of the presenting problem(s). For example:
It may be medically necessary to obtain a complete ROS when a patient presents as a new patient.
It may not be considered medically necessary to repeat a complete ROS on a follow-up visit.
If a provider uses a patient questionnaire to obtain information on the patient?s current signs and symptoms, the provider needs to acknowledge the review of the questionnaire as the source of the information, in the
office note, along with the provider?s signature and date on the questionnaire.
For new patient and consultation visits, the patient?s signs and symptom information (ROS) must be completely documented, including a description of each system that was reviewed during the encounter.
Established visits may use reference to a patient questionnaire. The ROS must be supported in the CC and
HPI. Documenting ?ROS negative? or ?ROS noncontributory? is not acceptable. The following
documentation is required, at a minimum:
Brief ROS documentation of positive/negative responses to problem pertinent systems directly related
to the chief complaint.
Extended ROS documentation of positive/negative responses for at least two to nine systems.
Complete ROS documentation of positive/negative responses for ten or more systems.
Any insight would be appreciated! Thanks-Sue