Wiki Review of Systems and blanket statements on every chart note

[ellzeycoding]

Had a client send me 10 charts to review.

Every chart note had the following, regardless of the reason for the visit... whether there was a single problem or a general exam.

CONSTITUTIONAL - normal
EYES - normal
EARS, NOSE, MOUTH, AND THROAT - normal
CARDIOVASCULAR - normal
RESPIRATORY - normal
GASTROINTESTINAL - normal
GENITOURINARY - normal
MUSCULOSKELETAL - normal
INTEGUMENTARY - normal
NEUROLOGICAL - normal
PSYCHIATRIC - normal
ENDOCRINE - normal
HEMATOLOGIC/LYMPHATIC - normal
ALLERGIC/IMMUNOLOGIC - normal


The problem I have is that this appeared on every note, regardless if there was a single problem with limited exam, or the patient was having a comprehensive examination and higher levels of MDM.

What questions were asked? What responses were negative or positive? Did the provider go through ALL of these systems, really? or just because nothing was mentioned by the patient, that everything is “considered” normal?

The Review of Systems should be an inventory or a list of questions asked by the provider that may uncover other conditions, symptoms, or relevant information that may be pertinent to the chief complaint or reason for the visit.

From this "cut and "paste" statement above, I don't know what questions were asked, what responses the patient has given, positive or negative.

E/M guidlines state that positive responses and pertinent negatives should be recorded. It also states that it's acceptable to mark "all other systems reviewed were negative".


This was a dermatology practice. Some of the patients were presenting with suspicious lesions or rashes. You'd "think" that there was but a positive response or pretinent negative on the Integumentary ROS at least?!?

 

[nomerz]

That's a huge red flag for an audit, unfortunately, for the exact reasons you stated... there is really no way to know what exactly was reviewed and if the systems are truly "normal."

 

[CodingKing]

The word normal is not sufficient. It needs to be more detailed as to what was normal. If everything was normal why the heck is the patient there in the first place? You just have to throw it all out and hope its an established patient or a MAC that allows billing established when all three components are not performed. Its a great way to lose in a malpractice case as well since a patient can easily lie later on that they told the doctor something was an issue but the doctor ignored it.