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Auditing ROS question

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bkudsk

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Winona, MN
Am auditing E&M codes and recently read that to obtain ROS credit, the system must pertain to the reason for the visit. Confusing as some of the webinars I've attended do not indicate that. Appreciate any assistance/advice. Thanks.
 
Ros

:oHi - Not sure where you read that, but that has never been my understanding. Did you read from a reliable source? I would love to see that.

Karen Gallagher, CPC, COSC:)
 
The guidelines discuss "pertinent positives and negatives", but if medically appropriate, you should give credit for any systems reviewed. I would never not give credit if it's documented, because it's not up to me to decide what system reviews are pertinent. I have never seen any guidance that says that you can't or shouldn't give credit for a ROS that is unrelated to the Chief complaint. As an auditor, I wouldn't ever be so presumptous as to say to a physician "Why are you reviewing that system? It's not medically necessary". Nope, I let them make that call, but I do remind them that they can't over-document just to bill out a higher level of service----for example if they always say "all others negative" when a patient comes in for a straightforward problem.
 
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