ROS question

dcandello

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Hi everybody. I was just wondering what exact verbiage was needed when a provider is dictating an ROS and they want to say they did a complete ROS with all systems negative and certain systems positive. Is the statement "A complete ROS was done and all other systems were negative except for (name the systems that were positive)." Or does it need "a 14-point ROS was done...." and add all the rest. Any help on this would be great! Thank you!
 
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SFeher

"A complete ROS was done and all other systems were negative except for (name the systems that were positive)." is sufficient
 

jdibble

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Hi everybody. I was just wondering what exact verbiage was needed when a provider is dictating an ROS and they want to say they did a complete ROS with all systems negative and certain systems positive. Is the statement "A complete ROS was done and all other systems were negative except for (name the systems that were positive)." Or does it need "a 14-point ROS was done...." and add all the rest. Any help on this would be great! Thank you!

Never say 14 point review, 10 point review, etc. as that is not appropriate and doesn't imply which systems were reviewed and are positive or negative. If there are positives he must state what the positives are - he cannot just list the name of the systems). If the system is pertinent to the reason for the visit and is negative, he should state the pertinent negative. We have our physicians state at the least 2 pertinent positives and/or negatives and then use the statement all other systems were reviewed and are negative.

Hope that helps!
 
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tjbd57

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Ros

Hi
The ROS statement has been a controversial topic over the years, but what I have learned is this; first and foremost it is best to check with your MAC to see what statements "they" prefer providers to use. Because in the long haul, they are the one's you are really trying to abide by in case of an audit. I perform audits for different regions and while most accept the same general statement as designated in the 1995/1997 Guidelines, Some do prefer to have the reference to a specific total, ie. "10 point ROS performed and was negative". But, they will also require that pertinent negative/positives must be noted in the HPI for this to be accepted. The fact still remains that - The 1995 and 1997 DG indicate, "a complete ROS inquires about the system(s) directly related to the problem(s) identified in the History of Present Illness (HPI) plus all additional body systems." The DG also state, "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."
When in doubt always refer to these guidelines and your MAC for help. Chances are you will find what you are looking for. Hope this helped instead of overwhelmed! lol
 
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I don't know if this helps, but here it is anyway:

"Both 1995 and 1997 E/M Documentation Guidelines define the ROS as an account of body systems obtained through questioning to identify patient signs and/or symptoms. The ROS might include verbal questioning by the provider or by a separate patient intake or questionnaire form. According to CMS’ documentation guidelines, the ROS can be obtained by ancillary staff (eg, nurse) or on a form completed by the patient. When a separate form is used, the provider must document that he/she reviewed the information along with notations supplementing or confirming the information."

"A complete review of systems can be documented by either individually documenting 10 or more systems, or by documenting the positive or pertinent negatives responses individually and adding a notation that all other systems were reviewed and are negative. Some carriers may allow the use of “noncontributory” in the documentation of a complete review of systems. Other carriers may consider “noncontributory” to mean it does not impact the treatment of the patient and therefore was not obtained. The payer guidelines should be verified when using “noncontributory.”

Medical necessity determines the extent of the ROS. For instance, it might be considered necessary to obtain a complete ROS when a new patient presents for an office visit, but medically unnecessary to repeat that complete review on every follow-up."
 
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