Wiki Organ Systems in ROS

[mhstrauss]

I'm hoping to get some guidance here on a question that was given to me by my admin. I don't think this is anything a coder should be making decisions on, but I'd like to hear what you all have to say.

We recently started using an EMR. When patients arrive for an appt, they are given registration paperwork that includes the ROS; the patient fills this out, and then MA enters the info into the EMR along with vitals, past histories, etc.

One of our docs is complaining that the info under ROS is too long, and wants a lot of it deleted, since we only deal with Neuro-related issues...so a lot of the symptoms on almost every other category is irrelevant to what we are treating the patient for. In my opinion (based on all the E/M guidelines I've read over from CMS and the AMA), it all needs to be on the form that the patient is filling out, but only positives and pertinent negatives should be entered into the EMR for the provider to review at that particular visit. I'm not clinical, so I'm not comfortable saying "Go ahead and get rid of everything on the form that doensn't have anything to do with Neurology".

So I guess the question is, Are we required to give patients the full ROS form at every visit?

I hope this makes sense; I know I tend to get a little wordy

Appreciate any feedback!!

 

[MikeEnos]

OK I'm a little confused by the wording but let me make a few statements that should clear things up:

- You are not required to do a complete ROS form for every patient. If it's part of your standard practice to have the patient fill it out as part of the registration/intake process, that's fine. The provider gets credit for checking as long as they reference the document was reviewed. The form itself should be dated and initialed by the provider. Note that sometimes patients don't follow directions, or outright refuse to fill out the form. You won't get credit in that case.

- There are a number of signs/symptoms and organ systems you might ask about that don't seem to be related, but might shed some light on the patient's problem(s.)

- To get credit for a complete review of systems, you must list your positive findings along with pertinent negatives (depending on the presenting problems) for the remaining systems, a notation that all other systems are negative will suffice for a complete ROS. If that isn't stated, all of the systems that are negative must be individually listed.
[Note: Trailblazer doesn't accept the 'all others negative' phrase- but who cares about them anyways? They lost their Medicare contract to Novitas Solutions anyways!]

 

[mhstrauss]

OK I'm a little confused by the wording but let me make a few statements that should clear things up:

- You are not required to do a complete ROS form for every patient. If it's part of your standard practice to have the patient fill it out as part of the registration/intake process, that's fine. The provider gets credit for checking as long as they reference the document was reviewed. The form itself should be dated and initialed by the provider. Note that sometimes patients don't follow directions, or outright refuse to fill out the form. You won't get credit in that case.

- There are a number of signs/symptoms and organ systems you might ask about that don't seem to be related, but might shed some light on the patient's problem(s.)

- To get credit for a complete review of systems, you must list your positive findings along with pertinent negatives (depending on the presenting problems) for the remaining systems, a notation that all other systems are negative will suffice for a complete ROS. If that isn't stated, all of the systems that are negative must be individually listed.
[Note: Trailblazer doesn't accept the 'all others negative' phrase- but who cares about them anyways? They lost their Medicare contract to Novitas Solutions anyways!]

Thanks for the reply, Mike! I think I have it all straight in my mind now; sorry that I wasn't very clear...sometimes I confuse myself too