Wiki Review of Systems

[medicalsec]

I know that it is appropriate to use "All other systems are reviewed and negative, or something in that general wording, but I am having a hard time getting our docs to use that terminology. I have advised them that if they do review 10 - 14 systems that they should note some of the postives and negatives and use this general wording to cover the remainder of the systems, but some of them will quote two or three of the systems and use the wording "review of systems is negative". In my mind, I would say that that leaves an open area as to the amount of systems that were reviewed. I told them that the key word is "all" or quoting the number of systems reviewed. I think that they think that I am going overboard with the requirement of the wording. I just wanted to have some other responses in writing so that I could reaffirm what I am saying. An example of how they word things is "Other than her back pain and shortness of breath, review of systems is negative"

Thanks,

Dee

 

[kbarbag]

HighMark Medicare says the wording should be "all other systems are non contributory" Some carriers accept "all other systems are negative" Good luck. Dr's hate Review of system

 

[LLovett]

http://www.wpsmedicare.com/part_b/education/2009_0615_emfaqdoc.pdf

Page 3.

Not sure who your carrier is but this is not acceptable for all carriers. If it is acceptable for yours they should have something similar on their site.

Good luck,

Laura, CPC, CPMA, CEMC