Most providers will list there ROS info in there HPI. It is usually easy to determine by negative / positive documentation. Then under review most will say: all other systems negative except for whats in HPI. Now the problem with this is making sure there really is ROS in the HPI. They can't use a statement about other systems if they did not review anything in HPI. For instance:
member is here with sore throat X 4 days. There is no ROS in this statement.
As a coder and auditor, I began by using the cross out method. Print a note and begin to cross off documentation for each section: For instance
member here with sore throat x 4 days. No fever, denies fatigue, hurts when swallowing, denies difficulty breathing.
I would look at my audit tool and determine what I have: I use E/M Audit Tool you can print this for free.
Under HPI I have location and duration
Under ROS I have: constitutional no fever, Respiratory no difficulty breathing, ENT: hurts when swallowing
Heres is something else to watch for: if provider uses that statement of all systems negative except for HPI then see if they listed all 14 systems as reviewed.. For instance if a provider says all systems then the question should be did you really do GYN / PSYCH / and if so what is the reason for this review. If they are only here for minor problem then documentation must support reason for visit as well.
Any other questions. please reach out. If I'm not sure I can help I will try to find an answer...hopefully
Sandi B. CPC, CPMA
sberry@cpnorthcountry.org