Wiki Ros requirements

[ebredehoeft]

I have a question. When a doctor is filling out the review of systems as part of determining which E/M code to use do they need note that they reviewed everything in a category. For example under ENT :Nasal mucosa, septum & turbinates or Lips, teeth and gums, etc. Or if they just note Nasal mucosa and no septum or turnbinates would they still be able to check off that yes they checked that area?

 

[FTessaBartels]

Review of Systems

There are 14 systems in the ROS. ANY remark, positive or negative, about the pertinent system(s) is counted as reviewing that system.

BUT I'm confused by your example, because I'm not sure it's the ROS vs the exam. And just naming the body part is not the same as a review of systems. The ROS is really looking at symptomology in the past (or absence of it).

The review of systems is the physician's query of the patient about symptoms or issues they patient may (or may not) have had with the various systems.

So, for example, when a patient presents with a chief complaint of wheezing and cough, the physician might ask if the patient has had any headache (neuro), sneezing or running nose (ENT), nausea (GI), chest pain (CV), itchy eyes (eyes OR allergy).

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[ebredehoeft]

Sorry I meant the exam. So if they were looking at ENT

For each bullet do they have to have note that they completed everything in the bullets. For example:

-External Ear and Nose
-EAC and TM's
-Hearing
-Nasal mucosa, septum and turnibates
-Lips, teeth and gums
-Oropharynx

So would they have to say they did an exam on external ear and note that they looked at the nose too or can they just look at the ear.