ROS Documentation


Shawnee, KS
Best answers
The 1995 documentation guidelines states the following:

(DG) At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. 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.

Would this statement be acceptable to bill for a complete ROS? "A 10 point review of systems was completed, all systems are negative except as noted above." Above is referring to the HPI.
what is in HPI?

I have to see what specifically is stated in the HPI - you stated "above is referring to HPI".

Are there pertinent positives & negatives stated in HPI that can be used as ROS without double dipping? Sometimes physicians combine it all together. If not, then I would agree no it would not qualify.