Wiki "Complete ROS" "All systems reviewed"

[nlbonn]

Hi all!!!

Provider documented "As noted above on HPI otherwise complete ROS is negative"
Less than 10 systems are usable, without double dipping, from HPI. Would you count this as a complete ROS? I was under the understanding it either needed to specify at least 10 systems, or say "All other systems."

 

[satishkumar.pharmacy86@gmail.com]

Yes

 

[Orthocoderpgu]

The answer could be no depending on what is documented per the 95 guidelines, page 7. Systems with pertinent positive and negative responses must be individually documented. After that stating "all other systems reviewed and clinically negative" is allowed. If you are getting all of your information from the HPI, I would make sure that there are HPI elements documented and pertinent ROS documented as well. With EMR's it's very easy for insurance companies to request medical records and they are asking for more medical records than they used to and taking back more payments as well. This type of documentation is what they are looking for. I would try to educate your providers on keeping the HPI and ROS separate, and still use this shortcut that is allowed.

 

[trarut]

I used to work for physicians who regularly documented the pertinent positives ROS elements in the HPI then used a "10-point ROS performed. Pertinent positives noted in HPI, all other systems negative." statement. We gave credit for a complete ROS. I'm only aware of one time it was questioned by an outside auditor in 10 years and we won that argument.