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Documenting all systems negative in ROS

  1. #1
    Default Documenting all systems negative in ROS
    Medical Coding Books
    If the documentation for the ROS is "as outlined above, otherwise all other systems are negative" can you count all systems? The physician is referring to systems mentioned in the HPI when documenting "as outlined above." I know you cannot give credit in both the HPI and ROS, but can the systems not relating to the HPI be counted by the documentation stating all other systems negative?

  2. #2
    This depends on your carrier. From what I hear Trailblazer says that is not acceptable, but the only info I have found from WPS Medicare (dated 2006) still says that it is acceptable. I am interested to see if anyone has anything more current stating differently. I have been educating providers to list the systems out individually because it seems that is going to be the requirement before long anyway, if not already in some cases.

    Laura, CPC

  3. Default
    This is what I found...

    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.

    I hope this helps...

    Thank you,
    Anthony McCallum, CPC, CIRCC, CPC-I, CCS

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