Wiki ROS statement

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scurcic

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Two part question regarding review of system statement.

1- We have a difference of opinion regarding the "10 point ROS reviewed and negative except in HPI" statement. Some feel the following "10 systems reviewed and negative other than pertinent positives and negatives as indicated per history of present illness" is acceptable others feel we should avoid using this statement and word it more like "all other systems negative except as noted in the HPI". Are both of these acceptable, especially to North Carolina MAC?

2- Should the HPI statement be one which is frowned upon, if the rest of the chart supports a 99285 (including HPI, PE; only the ROS has unacceptable verbiage), would it automatically become a 99284 based on this one issue? Or can a provider be queried with an "incomplete history" request.
 
I can't speak for the NC MAC, but in the practices I've worked with the verbiage '10 point ROS', without further detail about the ROS, was not something that could be used toward calculating the E&M level because there's no way from this to be able to know how many systems were actually reviewed. The second example you give is acceptable as it documents that 10 systems reviewed. 'All other systems negative' is not acceptable unless there is documentation of how many total systems were reviewed. However, if they had stated 'all systems were reviewed and were negative', then this would be OK. When possible, our providers were educated not to use language that did not make clear how many systems they reviewed.

To your second question, it would not be considered compliant to query a provider to add additional documentation solely for the purposes of raising the E&M level. Queries should only be made when there is unclear or conflicting information in the record that prevents you from being able select an accurate code. I would provide education for this but would not ask providers to amend existing records. Just assign the codes based on the information you have.
 
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