ROS acceptable or not----Adivce please

micki127

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Derry
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Hi,

Is this acceptable or not? Provider uses a form for the Review of systems that patient fills out. There is only 8 systems listed with the associated symptoms listed with it. The patient is suppose to circle all that applies or has experienced recently; which in this case nothing is circled. The form is reviewed, signed, and dated by patient and provider. The OV note contains this statement "Past medical history, surgical history, allergies, medications, social history, and review of systems otherwise were all reviewed and updated on today’s health history form."

Is this adequate to use when considering the HPI element. What in particular disqualifies this ROS for being used in the determination of an element for the HPI.

Is it disqualified because the provider did not state negative or positive to any/all systems that were reviewed. Also, if it was able to be considered would you allow the 8 systems even though nothing is cirled? Would that automatically be considered a negative as the patient did not have any of thosse symptoms affecting their systems?

Thank you for all you input in advance.
Micki
 

mitchellde

True Blue
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First he must state that he reviewed with the patient and indicate if there are any changes from the previous ROS and give the date of the previous ROS and where it is located, such as ROS from office note of 01/15/16 reviewed with patient and nothing changed, or updated as indicated. Since nothing was indicated and we have no idea from when it is being updated and we do not know if this was reviewed with the patient, then for this encounter there is no ROS. Perhaps nothing was circled because the patient felt too sick, or did not understand. There are many variables that are not addressed in your providers statement.
 
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Medicare Guidelines

Per Medicare Guidelines:

The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.

https://www.cms.gov/Outreach-and-Ed.../downloads/eval_mgmt_serv_guide-ICN006764.pdf

This is what I was taught when preparing for my CPMA exam.

Review of Systems (ROS)

The ROS should be documentation of how the patient is affected systemically by his or her chief complaint on the given date of service.

Upon completing the work of a complete ROS, the physician must make sure that he or she properly documents the information within the patient’s medical record. Physicians are required to document if the body systems reviewed are negative for systemic complaints by merely documenting negative or that the system demonstrates pertinent positive findings. It is not necessary for a physician to tell us within the ROS what the specific negative findings are; however, the documentation should list the specific pertinent positive findings. There are many effective ways the ROS can be documented. Forms of documentation may include:

• Listing each body system with the relevant findings
• Listing all negative systems together and then stating the pertinent positive findings
• Listing all pertinent positive findings and adding a statement that “all other systems are negative”

Some CMS contract carriers may not make allowance for statements such as “all other systems reviewed and are negative,” but national guidance does permit this form of documentation. When auditing, an auditor should refer to the specific contract carrier’s medical policy.

Hope this was helpful.
 
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