Wiki ROS is this acceptable?

[micki127]

Hi,

Can you please advise what you would give credit for?

Provider states in note (this is found in the HPI):

"no change in energy Yes. fatigue during wakefulness Yes. no leg movements with sleep Yes. no change in memory/concentration Yes. no change in mood Yes. nighttime urination Yes"

Now in the ROS paragraph it states:

"See 11 system ROS in HPI."

No where else in the chart or on a separate form is there any ROS documented. What you see is what there is. For one, there isn't 11 systems documented and two can only give credit for what is documented. I'm trying to assist a provider with understanding how the ROS is calculated when determining the E/M level and to amend the statement.

Also, is it adequate to state the below when not all 11 systems are documented?

"11 system review done and pertinent positive are listed in HPI"

Please offer any suggestions.

Thank you for any and all advice. It is much appreciated.
Micki

 

[Pathos]

Whenever I find a gray area when dealing with E/M guidelines, I always go back to CMS and my local MAC to see what they have to offer.

Per CMS E/M guidelines:

"Review of Systems (ROS)
ROS is an inventory of body systems obtained by asking a series of questions to identify signs and/or symptoms the patient may be experiencing or has experienced."

If documentation does not clearly state the Review of Systems (which can be collected in the HPI, as long as we don't "double dip"), and guidelines don't agree with any canned statements, then I would be skeptical in agreeing to the basis of the ROS.

To answer your question, I do not think that the example given qualifies for a Complete ROS, regardless of the statement used above. I do not see 11 ROS from the HPI, and I haven't even touched on what elements can be used towards the HPI.

CMS Guidelines do explain further:

"A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

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."

I list this statement with a word of caution that some payers do not recognize the blanket statement and requires the ROS to be separated out instead.

Finally, please remember that Medical Necessity always trumps over any fancy tools or guidelines, however since this term is so ambiguous, many people love distilling the medical chart into numbers and points. Quantifying the visit can be risky but can help streamline the documentation and auditing process.

Hope this helps!

 

[WaterJunkie]

Hi. The lack of components are only important for Consults or New patients. You can also use three chronic or inactive conditions to substitute for 4 elements of the HPI. I agree with Pathos in regards to MDM to correctly level the encounter.