Wiki Review of Systems

[Staceyw]

In the 1995 and 1997 CMS Guidelines for E/M services, the following comment is stated for Review of Systems:

"At least ten organ systems must be reviewed. 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 a notation, at least ten systems must be individually documented."

Based on the above comment, for a Review of System to be considered a "complete ROS", could a physician document the pertinent positives or pertinent negative review of systems and then mention that all other systems were reviewed and are negative? Or, do they have to list 10 review of systems regardless?

 

[Munzueta]

Hello Stacey,

There may be times when the patient denies any sign or systems for some of the organ systems being reviewed. It is permissible to facilitate thorough documentation for physicians to utilize one of several time-saving expression in order to convey the absence of signs or symptoms.

Some examples physicians can use for documentation of a complete ROS is:

"The remainder of the ROS is unremarkable"
"The remainder of the ROS is negative in detail"

the statements indicates that the patient denied any sign or symptom in the remaining ROS organ systems.

hope this helps,

Marco U. CIC, CPC
El Paso Texas AAPC Chapter President

 

[Staceyw]

Thank you for that!

 

[Munzueta]

Glad I could help!