Wiki ROS question - I am reviewing charts for

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Lkimsey

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I am reviewing charts for a pediatric GI doc and he writes in the ROS: A 12 point system review was done. Pertinent positives are abd pain, badbreath, and fecal soiling.
Since he states that a 12 point system review was done does this qualify for a complete ROS? I am really having a problem with this. Thanks for any info. Lynn Kimsey, CPC, CPMA, CPC-I, CEMC
 
I don't count it

Unless there is some specific documentation that shows that the 12 systems are (like a patient questionaire), I do NOT count this. There are 14 systems. They can use the shortcut if they reviewed ALL 14 systems, otherwise they have to specificate state which systems they reviewed.

Yes, I know this is pediatrics, and they feel foolish asking mom if 1-month old baby has had any psych problems, but there you have it.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Guidelines

Also ... point out to the doctor that the guidelines actually state you must complete a FULL review of systems and document at least 10 of those systems. So if he is documenting that he reviewed only 12 systems, it still doesn't count.

F Tessa Bartels, CPC, CEMC
 
Thank you all for the affirmation. This is a very difficult doctor to deal with but I agree that the rule is the rule. Thanks again for all your responses. Lynn Kimsey
 
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