Question Review of Systems Question

lottie66

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I need some help from some of you E & M experts. I believe the review of systems posted below would be considered a complete of review of systems. I know you have to have 10 systems in order to have a complete. If you disagree that this is a complete, please state why.

CONSTITUTIONAL: no fever, weight loss
EYES: No pain, no redness, changes in vision
ENT: no tinnitus, hearing loss
CARDIOVASCULAR: no chest pain or tachycardia
RESPIRATORY: no cough or shortness of breath
GI: no diarrhea, constipation, abdominal pain
GU: no dysuria
SKIN: no rash
NEUROLOGIC: no seizures, positive for headache
PSYCHIATRIC: positive for depression, anxiety, positive for sleep disturbance
 

twizzle

True Blue
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Sarasota FL
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I need some help from some of you E & M experts. I believe the review of systems posted below would be considered a complete of review of systems. I know you have to have 10 systems in order to have a complete. If you disagree that this is a complete, please state why.

CONSTITUTIONAL: no fever, weight loss
EYES: No pain, no redness, changes in vision
ENT: no tinnitus, hearing loss
CARDIOVASCULAR: no chest pain or tachycardia
RESPIRATORY: no cough or shortness of breath
GI: no diarrhea, constipation, abdominal pain
GU: no dysuria
SKIN: no rash
NEUROLOGIC: no seizures, positive for headache
PSYCHIATRIC: positive for depression, anxiety, positive for sleep disturbance
That would qualify as a complete ROS because 10 systems are individually and clearly documented.
 
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Hi,

I have a related question ....

For the ROS mentioned above, the provider only mentions ear issues for the ENMT system, is it necessary for the provider to say the other areas (nose, mouth, throat) are negative to count this system ? We have the same question for Hematologic / Lymphatic and Allergic / Immunologic systems, for example the provider may only comment on Allergic or may only comment on Lymphatic and Immunologic ? We have heard different answers from several auditors, some saying as long as one item is mentioned you can count the system and others saying provider must comment on all to count the system, so what we're looking for is a documented answer from CMS or other professional resource that we can refer back to .... can anyone help us ?

Thanks
Charlene
 

jcruz123

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Quesetion: Can this be used as a complete ROS?

12 systems were reviewed and are negative except as above.
Thanks,
Julie
 
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