Wiki Necessities for inpatient initial consult

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MWoessner

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When coding for 99221-99223, I have seen mixed reviews on what is acceptable for a complete ROS, some state that if you document the positive systems with associated symptoms, and write "all other systems reviewed and negative" it is acceptable for a 99222 or 99223 (with all other requirements being met, MDM, history, PE)

Ex:
Constitutional: fever, chills
Eyes: Negative
ENT: negative
Respiratory: negative
Cardio: negative
Gastro: negative
musculo: negative, except as documented in hpi
integumentary: negative, except as documented in hpi
All other systems were reviewed and negative.

or would be need to address: psych, neuro, endo, lymph, immuno as well to get all?
 
The statement that all other systems were review is acceptable for a complete ROS. Per the CMS guidelines for a complete ROS: "At least ten organ systems must be reviewed. 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."
 
ROS continued

Great, so continuing on with the ROS, what if the patient is demented or has an altered mental status and the ROS cannot be discussed?
Thanks in advance!
 
ROS continued....

What is the provider wrote,

All systems below were reviewed with the patient and negative, except for documentation in hpi:
constitutional
Eyes
ENT
Gastro
Genito
Cardio
Integ
Musc
Neuro
Psych
Immun/Lymph
 
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