Wiki ROS frequency

[GretaGrbo]

When auditing charts for compliance, I had a clinic ask if they are required to do a ROS evaluation on every visit or just once a year. I was under the impression that a ROS should be evaluated at every visit? Can anyone help me find information regarding this?
Thank you,
Densie

 

[thomas7331]

Providers are not required to do a ROS at every visit - it is up to the provider to determine the extent and the necessity of performing a ROS given each patient's presenting problem.

However, if the provider is performing an E&M service and wants to count the ROS toward the level assigned for the code on that visit, then per the E&M guidelines, the provider is required to document that they have reviewed and updated the ROS that is on file for the patient:

A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his/her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

o describing any new ROS and/or PFSH information or noting there has been no change in the information; and
o noting the date and location of the earlier ROS and/or PFSH.

 

[GretaGrbo]

Thank you! Where might I find this information?

 

[thomas7331]

Thank you! Where might I find this information?

The 1995 guidelines are here, documentation of history begins on page 4:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf

This is another helpful publication that has much of the same information - e.g. see 'Notes on Documentation of History and Exam' on page 11:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf