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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
    Location
    Baltimore East, MD
    Posts
    53
    Default
    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

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