Wiki Review of systems - help

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Mama3beartn

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Hello,

I would like the opinion and facts about the use of the phrase "All other systems Negative" used for ROS. I have tried to research this and am now more confused than before. So from an AUDITORS perspective how would you look at this.

I was coding a progress note... looked like it was a 99204. Then I get to the ROS and have to decide if it's now a 99203 due to lack of ROS. They only put three ROS then they put that controversial phrase, "All other ROS negative" Does this still count as a 10+ ROS?



Any help is greatly appreciated.

Thanks so much
 
Yes, a complete ROS was documented. The pertinent positives and negatives were listed first from what you are saying and all remaining review of systems are negative is an acceptable statement by 1995 guidelines.
 
As a post payment auditor we do not accept the blanket statement "all other systems negative". The provider must document what systems were reviewed. When I see this statement I go back to the HPI to see if I can abstract what systems were reviewed.
 
Everywhere I have worked at has accepted that phrase, but ONLY when there has been at least one other system reviewed.

For example we get a lot of the following:

Patient denies long bone pain, cough, dyspnea, fever and chills - all other systems negative.

Patient has fever, fatigue and all other systems negative.

I would recommend checking to see if the clinic you work at has a policy in place and then follow that.

For example, where I currently work we use an EHR where there is a ROS section - if the all other systems negative statement is in that location we don't use it because of how easy it is for the physician to pull that statement forward every single time. However if the statement is in the HPI section we can use it because that section requires them to type most of the information free-hand.
 
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