Results 1 to 3 of 3

Review Of Systems Documentation

  1. #1
    Default Review Of Systems Documentation
    Medical Coding Books
    I remember recently seeing some guidance stating that positives for the ROS should be stated individually and not just in the HPI. I cannot find it anywhere and cannot remember if it was from the OIG or CMS. Am I crazy or just google challenged?

  2. #2
    Baltimore East, MD
    The ROS doesn't have to be broken out under a separate heading, it can be included in the HPI in a paragraph format. Same goes for PFSH. There is nothing in the documentation guidelines regarding how HPI, ROS and PFSH should be formatted - although some carriers don't allow "double dipping" by counting the same element as both HPI and ROS.
    Lindsay Koschoreck, CPC, CPMA, AAPC Fellow
    2017 President, Charm City Chapter (East Baltimore)
    2016 Vice President, Charm City Chapter (East Baltimore)
    2014/2015 Treasurer, Charm City Chapter (East Baltimore)
    Region 2 - Atlantic (NJ, PA, DE, MD, DC)

  3. Default Ros
    I think that is in the e&m evaluation guidelines on the cms website. I use this a lot! Hope that helps.

    Josie J., CPC, CPC-H

Similar Threads

  1. Review of Systems documentation
    By akmorgan in forum Auditing General Discussion
    Replies: 4
    Last Post: 02-21-2018, 09:44 AM
  2. review of systems - enlarged lymph nodes
    By VRcoder29 in forum Auditing General Discussion
    Replies: 1
    Last Post: 05-08-2015, 06:24 PM
  3. Review of Systems documentation requirements
    By Donna Buchanan in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 04-06-2015, 07:02 AM
  4. Review of Systems - brought study guide
    By Naveen Rachagolla in forum E/M
    Replies: 14
    Last Post: 01-09-2013, 12:23 AM
  5. Review of Systems - type 2 diabetes
    By nperry in forum Auditing General Discussion
    Replies: 4
    Last Post: 03-31-2011, 01:01 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.