1formissy
Guru
I am hoping someone can shed some light on a problem I have with the ROS DG.
I have been an E/M auditor for many years, however, there has been some arguments between physician's and auditors with regards to the statement "...all other systems negative" for a complete ROS.
We have some provider's who document full ROS on ALL of their E/M records. It has always been a practice of mine, to review the ROS as being pertinent to the patient's presenting problems, and I have educated physicians whom I have instructed to report only those systems which are directly related to the presenting problems.
Here is an example:
Patient presents to the office with complaint of cough, and chest pain.
Checked ROS is pulmonary, and CV. Then the note says, "All other systems are reviewed and are negative."
My question is, " How would a full ROS be warranted for these complaints?"
We cannot deny based off medical necessity, we have to audit according to what is documented. Would those of you who are seasoned auditors allow a full ROS for this type of encounter?
Any help is greatly appreciated!
I have been an E/M auditor for many years, however, there has been some arguments between physician's and auditors with regards to the statement "...all other systems negative" for a complete ROS.
We have some provider's who document full ROS on ALL of their E/M records. It has always been a practice of mine, to review the ROS as being pertinent to the patient's presenting problems, and I have educated physicians whom I have instructed to report only those systems which are directly related to the presenting problems.
Here is an example:
Patient presents to the office with complaint of cough, and chest pain.
Checked ROS is pulmonary, and CV. Then the note says, "All other systems are reviewed and are negative."
My question is, " How would a full ROS be warranted for these complaints?"
We cannot deny based off medical necessity, we have to audit according to what is documented. Would those of you who are seasoned auditors allow a full ROS for this type of encounter?
Any help is greatly appreciated!