Ros -pertinent positive


Homer, AK
Best answers
ROS: 10 point review of systems was obained and there were no other known pertinent positive or negative ROS based on my interview with the patient today except those listed in the HPI.

Does this count for anything? My gut tells me it does not but I need to be certain before I talk to my providers because I do not want to be wrong on this one. It is my understanding that you have to have pertinent positives or negatives and this blanket statement does not count. Looking for guidance on this subject please and thank you.
CMS guidelines

I am quoting here from the CMS E/M guidelines. Reading 1995, but since ROS doesn't change between 95 and 97, this applies no matter what you do.

"At least 10 organ systems must be reviewed. Those stystems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissable."

Now this will depend on one's interpretation of "individually documented" but I don't count it as such when a positive finding is blended into the HPI. I would want to see that this is documented by the physician on its own merit, not just added in to get a positive finding.