I have a physician who wants to dictate "10 point review of systems were obtained; negative other than above" in his hospital dictation. What do you think? Is this sufficient?
My concern would be what other systems than above were obtained. Which are negative? I am not positive, but I don't think that would be suficient. If the doctor reviews all the systems, he might be able to state "all other systems reviewed and are negative, except for ones listed above". If you look under the 97 guidelines, it tells you
"DG: at least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be INDIVIDUALLY DOCUMENATED. 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."
Hope this helps
My caution to the physician would be to refrain from using that statement for every patient. "Remaining review of systems negative" or "all other ROS negative" are being scrutinized more these days.
I would not doubt it if that phrase is going to restricted for a complete 10 ROS in the future. It is similar to the wording "noncontributory" as being a no-no for PFSHx. I also agree with the coder who stated "medical necessity." Why would you need a complete ROS for a low level service? Again, using that phrase all the time would be a red flag.
Just my 2 cents.