ROS question

shanamarie

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Eagan
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Hello, this is an audit for a new provider, and I wanted to get some thoughts on what kind of credit to give for this?

Review of Systems:
A complete review of systems was performed and is unremarkable except for what is mentioned elsewhere in the note.
 

RyanRaichCPC

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Lawrence, KS
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In our clinic, no credit would be given for that ROS documentation as per our compliance department. The following is acceptable:

A 12 pt ROS including HEENT, Cardio, pulmonary, gastro, genitourinary, psych, neuro, musculoskeletal, endocrine, heme;immuno and integumentary system are all negative with the exceptions of joint pain and swelling.

We also will give credit for stating "a 10 pt ROS was performed with no pertinent positives"

They key here is the actual number of systems needs to be documented in order to be counted. Also stating that a ROS could not be performed due to dementia, unconsciousness, etc can also be counted as long as the reason is mentioned in the documentation as to why the ROS could not be obtained.
 

thomas7331

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Hello, this is an audit for a new provider, and I wanted to get some thoughts on what kind of credit to give for this?

Review of Systems:
A complete review of systems was performed and is unremarkable except for what is mentioned elsewhere in the note.
As an isolated case, I would probably allow credit for a complete ROS here, but I agree, to be safe in an audit, the provider should document the number of systems reviewed. I would give feedback to the provider to change their wording here.
 

Pathos

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CMS guidelines states:

"A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.
DG: 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.
"

While you might be able to get away with a generic statement, the more specific wording you have, the more solid documentation for the provider.
 

mcdream

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How much credit is given when an ROS cannot be performed & the reason is documented as to why the ROS could not be obtained?...complete ROS?
 

twizzle

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How much credit is given when an ROS cannot be performed & the reason is documented as to why the ROS could not be obtained?...complete ROS?
You are correct. In simplistic terms, as long as the documentation clearly states why a ROS cannot be elicited then credit can be given for a complete ROS. However, I was always taught that in those situations where the patient has difficulty answering ROS questions or where they are uncooperative, the provider should try to obtain ROS information from another appropriate source if possible and document that they made the effort.
 

Tonyj

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How much credit is given when an ROS cannot be performed & the reason is documented as to why the ROS could not be obtained?...complete ROS?
Good question.
I posed a similar question to a Medicare associate at a seminar once.
She advised that the level of service would be dependent upon the severity of the patient and documentation as a whole.
 
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