Wiki Question about ROS

[coder25]

I was wondering what you do when the office uses the ROS sheets and have the patient fill out the review of systems part. If the doctor initials this form and dates it, and then dictates that he reviewed the PMH and ROS with the patient today in the office, how do you know how many systems were really reviewed if the doctor does not give specifics. Is this something that I need to verify with the doctor? Is this something that I need to have him specify more clearer, like give positives and stated the rest of ROS were negative??

I am a newbie just learning E/M in the real world and want to be sure that I am coding the office visits correctly.

Thanks for your help!

Peggy, CPC-A

 

[FTessaBartels]

Using questionaire

If the patient has completed the questionaire and the physician has initialed/signed and dated, and also referenced this document in his clinic notes, then you give credit for whatever the patient completed on the PMFSH and ROS.

Ideally the physician will also make some statement as to pertinent positives or negatives, but even if s/he doesn't do this, you can still give credit for all that the patient completed on the form. (I've seen forms that don't have 14 systems on them. I've seen forms with 14 systems, but the patient only checks the few positives, or what the patient thinks is pertinent. I've seen forms with no social history questions. ...)

F Tessa Bartels, CPC, CPC-E/M

 

[coder25]

Thank you for your response. It is much appreciated.

 

[member7]

If the patient has completed the questionaire and the physician has initialed/signed and dated, and also referenced this document in his clinic notes, then you give credit for whatever the patient completed on the PMFSH and ROS.

Ideally the physician will also make some statement as to pertinent positives or negatives, but even if s/he doesn't do this, you can still give credit for all that the patient completed on the form. (I've seen forms that don't have 14 systems on them. I've seen forms with 14 systems, but the patient only checks the few positives, or what the patient thinks is pertinent. I've seen forms with no social history questions. ...)

F Tessa Bartels, CPC, CPC-E/M

Hi. Where do I locate that the physician must initial/sign and date the patient's questionaire to get credit for the ROS or PSFH? If they just initial, can I still give credit? I need citations to back me up. Thanks.