Wiki Doubledipping ROS and Exam

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A review of systems is obtained through questions to identify signs and/or systems the patient is either currently experiencing or has experienced related to the patient's complaint or problem. It is separate from the exam.
 
I was taught that you can't double dip. This was something my co-workers was questioning aswell. But we were told by a compliance auditor that double dipping is not allowed since HPI/ROS, Exam and MDM are considered seperate parts of a visit.
 
Same systems in both ROS and Exam

You can certainly have the same systems appear in both the ROS and exam. That does not mean you are double dipping.

The ROS is a subjective report by the patient in response to physician query of symptoms (or lack thereof) of the various body systems.

The Exam is an objective report by the provider of his/her findings on direct examination of the patient.

So the physician may note: abdomen tender in right lower quadrant. This means the physician actually palpated the abdomen and noted tenderness at the RLQ.

While the patient ROS might state: GI - positive for abdominal pain, no vomiting

Hope that helps.

F Tessa Bartels, CPC, CEMC
Hope that helps.
 
Basically, if the doctor document something in the ROS and not the EXAM, its considered double dipping if you try to use it in any other area. If the doctor notate similiar info in both areas, it's not considered double dipping.
 
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