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NESmith

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If my physician states in their documentation review of systems no other new complaints, is this acceptable and if it is what level would this be? Thanks
 
Hi
This is right from the CMS E&M guidelines on ROS


A complete ROS inquires about the system(s) directly related to the problem(s) identified in the
HPI plus all additional body systems.
!DG: 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
hope this helps
Robin Ingalls-Fitzgerald CCS, CPC, FCS, CEMC, CEDC
 
But does this mean the statement can be made. "ROS: see HPI" or "refer to HPI", and still get credit for that system, or does a seperate statment have to be made: for example the pt is being evaluated for coronary artery disease and for the CV system, "he had pressure symptom on the sternum on exertion"
 
As I understand it you cannot "double-dip" when auditing the History section of an E&M service. If you "borrow" something from the HPI to help your ROS you reduce the number of "points" in the HPI.
I have done this on some audits where the physician may have documented 4 or 5 items in the HPI but only checked "All other systems reviewed and are negative" w/o documenting any symptomatic systems - this is a not acceptable as a comprehensive ROS. I would borrow a point from the HPI to at least bring the ROS to expanded problem focused (problem pertinent) but would reduce the HPI by one.

Hope this helps.
 
Negative, unremarkable, or non-contributory

Hello,
I want some advice on the ROS verbiage. Per the documentation guidelines, "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." and this is what my department follows.

However, we do not allow the verbiage "...the remainder of his review of systems is "unremarkable" or "non-contributory". Do other auditors allow such terms and if so, what is your reasoning?

Thanks in advance for everyone's input. :)
 
Similar verbiage

When the words are similar to "negative" , such as the examples you gave like "non-contributory" or "unremarkable", we count that as the same as documenting "all others negative." I interpret "negative" as meaning that that particular system is not a factor in this patient visit - therefore, I believe that those terms are meant in the same context - that these systems are not a factor in the current visit.
 
I sent this very same question to my local carrier, FCSO and this was the response.

1. If I document the most pertinent systems under the ROS, review the rest of the systems but document remaining 13-point review of system was unremarkable or non-contributory, will I receive credit for a complete ROS.?

1. If the remaining systems were, indeed, reviewed and were found to be unremarkable, yes. Avoid the use of 'noncontributory', as it implies the system was never inquired about.

I do not allow non-contributory, however I will allow unremarkable.
 
ROS located in HPI

Per our carrier, Highmark, they state that the ROS can be included in the HPI. They do not consider it "double dipping" as it is all part of the history taking. They say it is not necessary to document the ROS separately and it all could be included with the HPI. I usually look for at least 4 HPI and use what is left to be applied to ROS, along with their statement under their personal history of status of allergies. So, I would check with your specific carrier to see what they want.

Some of my docs document the ROS separately (and those usually include the "all others negative" statement), others do one paragraph, but usually fall short of a complete ROS as they do not use the statement. I am in the process now of trying to educate them on the proper documentation of what they have done.

Jodi Dibble, CPC
 
we require our docs to dictate pertinent positives and negatives in the ROS, and then notate the number of systems that were reviewed and found to be non-contributory. e.g., "Abdominal pain, leukocytosis. Remainder of 14 point review of systems was non-contributory". It's a small item, but it makes the documentation less open to interperetation. If you just say "ROS was negative", then how can you apply an E/M code? You don't actually know how many systems were reviewed.
 
How about the statement, "patient has no other complaints"? My doctors always speak about the pertinent positives in the HPI, then will say that the patient has no other complaints. Is that sufficient to a complete ROS, as the ROS is usually in the patient own words? Or does it have to list the systems that patients has no complaints about?
 
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