Wiki Ros??

[JDACPC]

Debate going on about whether there is ROS documented:

Clinical history: Venous insufficiency
Consultation: The patient presents for evaluation and consultation for possible left lower extremity vein treatment. The patient reports a longstanding history of varicose vein problems resulting in pain, cramps, tiredness, heaviness, numbness and a burning sensation exacerbated by extended periods of standing, walking and exercising. The patient reports only mild improvement in her symptoms with use of compression stockings. The patient has had prior sclerotherapy for small spider veins.
On physical exam...

It looks like a nice HPI to me but no other body area to pull out for ROS. Your thoughts?

Thanks!

 

[Naveen Rachagolla]

May be your r correct !

Even i dint find any ROS to pull, Because..

The ROS review of system is a distinct review of a system. For example, if the documentation states "The patient states she has a sore throat." Credit would not be given to both the HPI location and to the review of the ENT system. If on the other hand, the documentation states, "The patient states that she has a sore throat. She dinies any postnasal drip of fullness in her ears when she swallos," then there is a distinct component of both the HPI and also the seperate ENT system review. Review of system elements typically refernce sings and symptoms of which both positive and negative comments are considered. Auditors commonly watch for indicators of a question what has been asked by the physician or provider and answered by the patient.

Both the 95 and 97 DGs define an ROS as an account of body systems obtained througth a sereis of questions seeking to spot signs and/or symptoms that the patient may be experiencing or has experienced. This query is made by the physician and/or by the staff verbally or via a patient intake form to best define the patients total problem.

 

[JDACPC]

Thank you so much! And that is a great "plain and simple" explanation that maybe the doc will understand.

 

[chelle1031]

Ros

When scoring the review of systems (ROS), can you use the systems addressed in the history of present illness (HPI) elements or is that "double dipping"?

ROS inquiries are questions concerning the system(s) directly related to the problem(s) identified in the HPI. Therefore, it is not considered "double dipping" to use the system(s) addressed in the HPI for ROS credit.

Date Posted: 10/16/2009, Date Revised: 10/01/2012

This information was taken from Novitas Solutions which is the J12 Medicare contractor.