Help: ROS negative findings-- what is appropriate?


Barboursville, WV
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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 dealing with questions from a provider right now, who wants something in black and white explaining the rationale behind this.
Thanks for your time
You can find the CMS guidance on this in the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services which are available on the CMS Medicare web site, and which are an excellent source to reference first for all of your provider's questions about E&M documentation expectations. (In fact, I have often printed this and given it to providers for their use as a reference.) Regarding the negative findings in the ROS, the guidelines state that for a complete ROS: "Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.."
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