Wiki ROS negative except as documented in HPI question

[calorom2]

I would appreciate any thoughts on this as there isn't agreement in my office. Would this be acceptable documentation for a 10pt ROS?

Thank you?

Review of Systems Constitutional: Negative except as documented in history of present illness.
Eye: Negative.
Ear/Nose/Mouth/Throat: Negative.
Respiratory: Negative except as documented in history of present illness.
Cardiovascular: Negative except as documented in history of present illness.
Gastrointestinal: Negative.
Genitourinary: Negative.
Musculoskeletal: Negative.
Neurologic: Negative.
Psychiatric: Negative.

 

[calorom2]

Any one have any thoughts on this?

 

[Mayzoo]

I believe that would acceptable. Here are a few links to review.


https://www.aapc.com/memberarea/forums/51215-ros-systems-negative.html

And many others...I just looked this up a few days ago, so I had the links handy.

 

[Pathos]

I commonly refer to the CMS guidelines whenever there is a question regarding E/M documentation.

The guidelines explain:
"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."

The example you are giving, seems acceptable. However, as with most E/M documentation, always check with the patient's payer for any specific E/M policies/guidelines.