Wiki Help with ROS!!

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l1ttle_0ne

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We are starting to audit at our clinic. This is what one of our physicians puts in for his review of systems for each patient.

"Review of Systems: Please see the form on the chart dated 12/17/2014, that was reviewed today with changes noted above."

When the patient first comes in they have them fill out a review of systems form. So this is what he's referencing. Every visit that he has with the patient he just references that form, and states if there are any changes or not. Is this OK for the doctor to do?? I'm not really sure, and I'm new to this auditing. So I would just have to look at that form, to get the ROS when auditing?? I'm confused!! Can anyone help?! Please!
 
Thank you! One more question, can you use this as a full ROS??

ROS: ROS negative except for HPI

I believe you can, but I'd like to double check.
 
Yes you can use that statement, however, if you are going to request a change of statement I would consider "ROS 10 point review negative except for HPI". In this statement all bases are covered and would pass any RAC audit.
hope this helps some.
 
No, this would not be appropriate

There are 14 recognized systems for ROS and there are only 2 appropriate ways to document a complete ROS. 10 or more individually or pertinent positive and negatives individually with a statement of "all other systems reviewed and are negative". Below are a statement from WPS Medicare along with the official guidelines.

http://www.wpsmedicare.com/j8macpartb/resources/provider_types/evalmngmntqa.shtml

Q9. The 1995 and 1997 DGs indicate "all other systems are negative" is acceptable for a comprehensive level of the Review of Systems. Does WPS accept this?
A9. Yes. For a comprehensive ROS, the physician must document the review of at least 10 organ systems. The physician must document both the positive and the problem pertinent negative responses relating to the chief complaint. Indicating the individual systems leaves no room for doubt as to the number of systems reviewed, but "all other systems negative" is acceptable.

https://www.cms.gov/Outreach-and-Ed...N/MLNEdWebGuide/Downloads/95Docguidelines.pdf

A complete ROS inquires about the system(s) directly related to the problem(s)
identified in the HPI plus all additional body systems.
DG: At least ten organ systems must be reviewed. Those systems with positive
or pertinent negative responses must be individually documented. For the
remaining systems, a notation indicating all other systems are negative is
permissible. In the absence of such a notation, at least ten systems must be
individually documented.


Stating 10 systems is insufficient since there is no way to know which of the 14 were reviewed.

Laura, CPC, CPMA, CPC-I, CANPC, CEMC
 
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