1. N

    "Complete ROS" "All systems reviewed"

    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...
  2. A

    Question Acceptable ROS/PFSH notation?

    My provider usually documents ROS/PFSH for establish patients as such: PAST MEDICAL HISTORY, SOCIAL HISTORY, MEDICATIONS AND ALLERGIES: Reviewed and not changed since last visit. REVIEW OF SYSTEMS: Reviewed in chart and signed. Per E/M guidelines, the provider has to indicate that the...
  3. Z

    ROS Confusion

    Can a Review of Systems be counted as complete if it appears as the following on a note: Review of Systems Below systems reviewed with the patient's wife, all are negative except as noted above General ROS Allergy and Immunology ROS Hematological and Lymphatic ROS Endocrine ROS Respiratory ROS...
  4. C

    Help: ROS negative findings-- what is appropriate?

    I have always been taught that in auditing a chart note that the word "negative" will not count, and for at least one body system needs to specify the negative findings and then the provider can say all other systems negative. Is this correct? Does anyone know What Medicare rules are? I am...
  5. P

    Review of Systems audit perfection

    I am the Medical Director of a surgical group practice. We recently started using a new auditor for our medical records. The new auditors keep excluding our Review of Systems as invalid because they might not exactly match the rest of the medical record. I have argued that the review of...
  6. K

    E/M coding, ROS

    when coding E/M, does anyone know if a doctor states hx of colectomy, hx of appendectomy, hx of CABG, ext, for example, can you use that as ROS, if he only states past surgeries?
  7. B

    Review of systems

    On the examples below regarding the ROS would the statement suffice for a complete ROS: REVIEW OF SYSTEMS: Review of systems x 12, denied except for acute gouty arthritis. or just Review of systems x 12
  8. R

    Physical exam

    How many ROS need to be listed for a complete physical exam?
  9. A

    Intake and Output

    Where would you count Intake and Output? Would this be counted in ROS or Exam?
  10. M

    Coding & ROS

    I have a question on whether you can use elements from ROS for your exam components? For example, the documentation has 12 elements in ROS and there are only 7 elements in the EXAM component - can you use elements from ROS in the EXAM component to get a comprehensive level? I was always taught...
  11. R

    Need assistance on ER leveling.

    Case #1.. Patient came in with final DX of strain of muscle/fascia on lower back. Complete HPI, ROS and Exam. physician did x-ray and prescribed Norco q6 PRN. (not admitted) They recommend 99284 code , as I was thinking it was just 99282 or 99283? Case#2.. Final Dx: Contusion Left Hip...
  12. I

    ROS question for Gastrointestinal

    I work in a gastro clinic. Under the ROS for Gastrointestinal my physicians have been stating Please see HPI. Is this acceptable? Thank you.
  13. Stefanie

    ROS Question and Exam Bullet Question

    Our clinic uses strictly 1997 Guidelines.. ROS: 1. Does anyone use "ALLERGIES; Sulfa" or "NKDA" as a ROS? EXAM: 2. Provider states: "Patient is alert and oriented x3", is there anyway to justify using "alert" as a bullet in pysch? I know that oriented x3 is one, but when you only need one more...