Counting points on Review of System

coder103

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I am seeking a 2nd opinion on regards to review of system. A chart shows the triage note of ROS done by a nurse. All the review of systems was completely assessed. The doctors notes/template shows that he was marking only 6 organ systems (1995 guidelines). Yet, he noted/marked that he had reviewed the nursing assessment. Should I consider counting the ROS as complete? If you can provide reference/article that will be great, too. Thank you for your feedback!
 
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ROS complete

It would help to see the actual note / wording of the reference.

But in general, yes, the physician does not have to complete the ROS him/herself, but can refer to a questionaire or other record in the chart where a complete review of systems has been done - AS LONG AS ... the physician must refer to the specific document ("see nurse's note" is NOT sufficient) by date and who completed it, AND must state that s/he (the physician) reviewed this document and concurs - even better list separately any pertinent positive or negative items.

So, for example, let's say you have a patient who presents with diarrhea and stomach cramping. The nurse fills out the ROS questionaire (all 14 systems reviewed). The doctor might say something like: "I reviewed the ROS questionaire today and of note: only previous GI problem was appendectomy at age 6, no recent fevers or unexplained weight loss or gain. For the remainder of the review of systems, please see the ROS questionaire completed by nurse A mm/dd/yy."

The Review of Systems requirement is the same whether using 1995 or 1997 guidelines.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

coder103

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Thank you Tessa for your detailed explanation! All the charts are in template forms. What the doctor is doing is just marking or checking the boxes except if he finds things unusual.
Am I right to say that the nurse notes is a reference in inventory of organ system of which that doctor must/has reviewed and has marked that he did. In order to consider counting a complete ROS?
 
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Yes, he should sign/date

The doctor should at least sign (or initial) and date the form the nurse has completed to show that he reviewed it. If you are audited and there is no reference in the "main" note to this additional documentation then your physician probably won't get credit for a complete ROS.

Next time you revise/re-print your template, add "Patient ROS questionaire dated _____ reviewed this date" with a check box next to it.

F Tessa Bartels, CPC, CEMC
 
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