Wiki ROS 14 point review

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If the physician documents 6 ROS in the HPI and then documents ROS: 14-Point ROS negative except as listed above. Would this be compliant to give a comprehensive ROS?
 
Hello,

yes, physicians can use that sort of documentation to go for a "complete ROS." They can use any similar phrases stating "the remainder of the ROS is unremarkable" or "negative" and just like in your case, also added the "except as list above."

The only thing we coders have to look into, is to make sure this is being used properly, and how does that work?

Meaning if they have patients for small problems, lets say a patient complaining only about pain in the leg and nothing else, and they do a "complete" ROS, is it really justifying it? this is when we can to make sure physicians aren't just saying "all ROS negative" to get a higher level when is not medically necessary to do a complete ROS.

Let me know if this helps.

thanks!
 
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