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ROS vs HISTORY Documentation

  1. #1
    Default ROS vs HISTORY Documentation
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    When auditing, what would you consider the phrase "Denies history of..." as? I had considered it part of the past history review but my doc is insisting it's an ROS. He uses this phrase throughout his ROS-Denies history of depression, Denies history of Crohn's, Denies history of stroke, etc. In many cases, the denials are the only thing about that system in the ROS. Any thoughts will be appreciated!

    Sue

  2. Default
    I would consider that a review of past medical history. By definition the ROS should consist of the review of any current systems that patient has a complaint regarding. Stating that patient denies Crohns, etc.. does not constitute an ROS. The provider is not reviewing the GI system but merely stating that patient does not have a hx of Crohns. There are still a thousand other GI complaints/diagnosis that still could exist.

    At my workplace we participate in monthly external audits and that would not fly as ROS with any auditor or coder that I know.

    Hope this helps.

  3. #3
    Default ROS vs. HISTORY Documentation
    I disagree and think that you are trying to work within too narrow a definition. There can be fine line at times between ROS and Past Medical History. Review of Systems is defined by CPT as “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that patient may be experiencing or has experienced.” This definition does not just include current symptoms, but also symptoms that may have occurred in the past.

    Documentation Guidelines state that the physician should be given credit for "positive or pertinent negative responses." Physicians commonly document pertinent negative responses with the term "patient denies" and frequently add "history of" as a way of saying anytime in the past. The physician is not obligated to ask about all possible symptoms for each given system, instead they are only required to query the patient about specific concerns they feel to be pertinent to the patient's presenting problem. The physician is also not obligated by any of the existing rules to specifically list positive findings. As a result, any given ROS documentation may reflect only pertinent negatives.

    Simply using the term "denies history of" should not exclude the statement as ROS. Statements such as "denies history of frequent diarrhea," "denies history of joint pain," or "denies history of vision problems" whould clearly be ROS in my experience.

  4. #4
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    Default Agree
    Very well said, Randy. I absolutely agree.

    F Tessa Bartels, CPC, CEMC

  5. #5
    Default A nice explanation, Randy
    I completely agree with Randy's statement. This is what I was formulating as I read the question. Basically, include in the ROS anything the provider ASKED the patient about. For the Past History, count what the patient EXPERIENCED in the past.
    For example, if a patient is seen for vision problems and the provider asks about diabetes and the patient says "no" and the provider writes "denies diabetes" that would count towards ROS, the patient also points out that 5 years ago s/he had a biking accident and was poked by a branch extremely close to the eye, that would be past history.
    Hope this is helpful.
    K

  6. #6
    Default
    Thank you to everyone for your input!
    So, from what I'm reading, most everyone would be comfortable taking "denies history of" as an ROS. Before I share this info with my fellow coders, does anyone have any insight as to whether or not Medicare would take the same view? We try to make our documents Medicare audit-proof which is why we tend to be more conservative in our interpretation of guidelines. How do your offices handle the big bad threat of the RAC audit?

  7. #7
    Default
    I view a review of systems as a review of SYMPTOMS the patient is (or isn't, if pertinent) experiencing whereas the patient's past medical history is a history of diagnosed diseases. For example, the patient has a history of Crohns disease and is experiencing abdominal pain, but no arthralgias would be a past history and a GI and MS ROS.
    Jenny Berkshire, CPC, CEMC, CGIC

  8. #8
    Default
    Quote Originally Posted by randykautz View Post
    I disagree and think that you are trying to work within too narrow a definition. There can be fine line at times between ROS and Past Medical History. Review of Systems is defined by CPT as “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that patient may be experiencing or has experienced.” This definition does not just include current symptoms, but also symptoms that may have occurred in the past.

    Documentation Guidelines state that the physician should be given credit for "positive or pertinent negative responses." Physicians commonly document pertinent negative responses with the term "patient denies" and frequently add "history of" as a way of saying anytime in the past. The physician is not obligated to ask about all possible symptoms for each given system, instead they are only required to query the patient about specific concerns they feel to be pertinent to the patient's presenting problem. The physician is also not obligated by any of the existing rules to specifically list positive findings. As a result, any given ROS documentation may reflect only pertinent negatives.

    Simply using the term "denies history of" should not exclude the statement as ROS. Statements such as "denies history of frequent diarrhea," "denies history of joint pain," or "denies history of vision problems" whould clearly be ROS in my experience.
    I got the same responose from my Doctor in our facility

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