Wiki Review of Systems help!!

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mdwyer

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We have a physician who sees patients in our clinic area and tends to roll parts of his ROS together. Can you only count the systems that he categorizes out?

For example:
REVIEW OF SYSTEMS:
CONSTITUTIONAL - no change in appetite, no fever
EYES - no double vision
ENT - no ringing in the ears
CVS - no chest pain, no shortness of breath
GI - no nausea or vomiting
ENDOCRINE - no dry skin
NEURO - no dizziness, no routine headache, no falls
PSYCH - no suicidal ideation/plan
MUSCULOSKELETAL - no tenderness

Can we use "no shortness of breath" from under CVS and count it as RESPIRATORY system as well?
Can we count "no dry skin" as INTEGUMENTARY system too?

He claims he should be getting full 10 system credit for what is provided above but we are trying to get him to list them out individually.

Any thoughts?
Marlisa D, CPC
 
You can count whatever he documents. It does not have to be listed under any particular header.

A statement such as "no N/V/D, headache, sore throat, or coughing." gets the same credit as if it was listed as
"GI- No N/V/D.
Neuro- no headache.
ENT- no sore throat.
Resp- no coughing."

I would agree that he has 10 systems there.

Laura, CPC, CPMA, CEMC
 
LLovett said:
You can count whatever he documents. It does not have to be listed under any particular header.

A statement such as "no N/V/D, headache, sore throat, or coughing." gets the same credit as if it was listed as
"GI- No N/V/D.
Neuro- no headache.
ENT- no sore throat.
Resp- no coughing."

I would agree that he has 10 systems there.

Laura, CPC, CPMA, CEMC
Click to expand...

I didn't know we would be allowed to "rearrange" things in the ROS. Thanks for this. :)
 
Thanks for the information. Our 3M encoder provided us with this information:

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 notation, at least ten systems must be individually documented.

And it almost seems like they have to be listed INDIVIDUALLY. Is there a spot that can confirm that we can divide this out so that I can present it to the other coders?

Marlisa. CPC
 
I think you are reading that statement the wrong way. They are saying pertinent positives and/or negatives must be listed individually. They don't have to be under their own systems header, they just have to actually be listed. Once this is done the provider can lump all other negative system reviews into one statement such as "all other systems reviewed and are negative" and get credit for a Complete (10+) ROS. If they don't use this statement they only get credit for the number of systems actually listed.

No N/V/D, headache, fever, cough, or sore throat. All other systems were reviewed and are negative. This would be a Complete ROS

No N/V/D, headache, fever, cough, or sore throat. By itself you would only get credit for 5 systems which is an Extended ROS.



Hope this helps,

Laura, CPC, CPMA, CEMC
 
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