Wiki ROS question/auditing

[jpinelli]

Can you please tell me if stating "all others reviewed and negative" is the only acceptable statement to receive full credit under the ROS? I am seeing other verbiage used such as " other 10 system review performed, no other pertinent positive responses".

 

[ARCPC9491]

Check with your contractor. Trailblazer doesn't allow it.

There are 14 systems .... if you say 10 system review -- what systems are you reviewing? This is why Trailblazer wants you to list them individually.

You also have a liability here ... providers may just be saying "all reviewed" to get a complete ROS. But also, say you have a patient that walks out of your office and has a heart attack and your ROS says positive for fever, all other reviewed and are negative? Many providers are NOT using this "short cut" because it is indeed a liability/malpractice to them if they abuse it.

Food for thought.

 

[RebeccaWoodward*]

I agree with AR...check with your carrier. My carriers view.....

Complete ROS Examples

Chief complaint=shortness of breath

“No chest pain or cough. All other systems were reviewed and were negative.”

Systems reviewed:
If a complete review of systems is medically necessary, then 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.