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ROS Confusion

  1. Default ROS Confusion
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    Can a Review of Systems be counted as complete if it appears as the following on a note:

    Review of Systems
    Below systems reviewed with the patient's wife, all are negative except as noted above
    General ROS
    Allergy and Immunology ROS

    Hematological and Lymphatic ROS
    Endocrine ROS
    Respiratory ROS
    Cardiovascular ROS
    Gastrointenstinal ROS
    Genito-Urinary ROS
    Neurological ROS
    Dermatological ROS.

    Also, if the patient is unconscious or mentally disabled and it is noted that a ROS was unable to be obtained because of the patient's status, does that count as a complete ROS?

    Thank You!

  2. #2
    Medical Billing
    The CMS E/M guidelines explain:

    "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."

    "DG: If the physician is unable to obtain a history from the patient or other source,
    the record should describe the patient's condition or other circumstance which
    precludes obtaining a history.

    So in short, yes if the documentation supports it.
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

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