No ROS done


Pittsburgh Central Pennsylvania
Best answers

I am looking for suggestions and input for this scenario. I am fairly new to E&M code reviews and am stumped on this.

A new patient presents to the office. I have read the documentation through and through and found that no Review of Systems was done. I asked the provider, who responded, states he did not do a review of systems. Pt is intellectually impaired and a poor historian. I have no idea now what this means for the History portion of the evaluation and management.

Is the history element booted down to problem focused because no ROS was done? I have not had a coding situation before where an ROS was NOT done.

Does anyone have any knowledge or suggestions? I'm stumped :(

Thank you!

Pam Brooks

True Blue
Local Chapter Officer
NAB Member
South Berwick, ME
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There doesn't have to be a specific, labeled ROS section in the note in order to abstract a system review. There may be something elsewhere in the note that would suffice. Medical notes are not always listed and compartmentalized in the way auditors would like to see them, so you often have to read carefully to get the full story. I once coded for a hospitalist who indicated much of the patient's HPI as a narrative documented within the Assessment and Plan.

However, if there is nothing in the note that would suggest that the patient was queried about any OS symptomology or status, then you'll have to go with the PF History.