Wiki Review of Systems - give me guidance

[jmcalhaney]

I was wondering if anyone could give me guidance on an issue I am seeing. I have pasted the note just to show you what I am talking about. I am concerned that the physician is basically telling me to "double dip." His ROS is the same statement for every patient and I believe that he should state the pertinent positives instead of referring me back to the HPI.

History of Present Illness: This is an 85 year old female presenting for evaluation. The patient reports shortness of breath at rest and with minimal exertion. She denies any cough. No fever or chills. No night sweats. No weight loss. The patient denies any snoring. However, she wakes up many times through the night. She sleeps more than 12 hours and is still tired and takes naps during the day.

ROS: Negative 10 point review of systems except otherwise mentioned in the history.

 

[LISAGASHO]

It is my understanding that it depends on your Medicare carrier. Some Medicare carriers accept this type of statement, 10 point ROS all negative except positive mentioned. You might want to look at your carriers guidelines.

This is just my understanding, so please research with your carrier further.

Thanks

Lisa Gasho, CPC

 

[FTessaBartels]

There are 14 systems

There are 14 systems. If the provider wants to use a "shortcut" in documenting a full ROS then the shortcut must indicate that ALL systems were reviewed. If the provider reviewed fewer than all 14 systems, then the systems that were reviewed must be specifically documented.

I wouldn't give credit for anything other than those systems found in the HPI.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[mariapuerto5@gmail.com]

The correct wording "word by word" should state "All others systems were reveiwed and are negative" and if the provider wants to add "except for what is noted in the HPI" that would be fine. If they opt to do this, they must document the pertinent postives and/or negatives in the HPI and/or ROS. My experience, the 10 point system notation is not allowed by most MAC.