Wiki E & M review of systems

[Jlokloski]

I need some clarification regarding the review of systems. To get a complete ROS does the doctor have to dictate 10 systems and then state that the remaining 4 are negative or is it permissable for the doctor to dictate 6 and then state except for those mentioned above, 14 systems were reviewed with the patient and all are negative?

Thank you for your help

 

[codingwithkelly]

I've always instructed my providers to document all the pertinant positive/negative ROS as it pertains to the presenting problem and then document "the remaining systems were reviewed and are negative". Try and stay away from an actual # of systems. It's easier for the providers to document w/o counting systems.

Remember the presenting problem(s) must warrant the comprehensive ROS and I ask my providers to document at least 4 pertinant positive/negatives before using the blanket statment.

Hope this helps!