Wiki ROS Elements


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If the ROS element is not pertinent to the chief complaint or presenting problem, can you count that as a point towards the review of systems?

Also, if the doctor refills a prescription, or the treatment of a condition such as ADHD does not change during an office visit, then the coder should not give points towards the "Number of Diagnosis or Treatment Options" section of the audit tool?

Thank you!
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If you could only count systems that were pertinent to the chief complaint then you would almost never have a complete ROS ... There is no requirement that the systems covered in the ROS be relevant to the chief complaint.

Prescription drug management is counted in the table of risk when determining the level of Medical Decision Making.

Hope that helps.

F Tessa Bartels, CPC, CEMC