Wiki Review of Systems

[ShelleyM]

This may be a stupid question, but I need to ask it all the same. I understand the ROS to be asking the patient if he/she is currently having symptoms in that particular system of the body at the appointment. Is that correct? It is not a place to list previous medical history. Our office has the medical history and ROS combined and I'm not sure that is compliant.
Just need some clarification from my coder buddies!
Thank you!

 

[OCD_coder]

You are correct, see the attached paragraph from the 1995 Documentation Guidelines.

REVIEW OF SYSTEMS (ROS)A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced

If the provider documents -/+ GERD, diabetes, hypertension without a sign or symptom specific question they would be credited in the Past Medical History portion of the History component.

 

[mitchellde]

ROS is in the history section, think of as " do you have, have you ever had....."

 

[kak6]

Providers may list their ROS in any form in any place it is up to the coder to sort it out, however, i would speak to the providers and ask if they could separate their documentation for the convience of the codering. Also i would count + gerd as gastrointestinal unless pt stated 'no longer has gerd' but + means they currently have it. You need to see the areas of concern documented then provider can state all other systems negative. Of course I'm sure you already know, anyone can document ROS and provider state they have reviewed and confirm to count.

 

[ShelleyM]

Thank you all for your help! It is much appreciated!!!!

 

[solocoder]

So, can past medical history information that is listed in the ROS be counted toward medical history instead of toward ROS if needed?