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Chart Audit

  1. #1
    Default Chart Audit
    Medical Coding Books
    I am in the process of performing chart audits on my providers. We have an electronic medical record and was wondering if you would give credit for this statement under Review of Systems: "No additional health concerns" that is the only statement under Review of Systems.

    I am inclined not to give credit for this statement. Please help!


  2. #2
    Wausau, Wisconsin
    In our facility our Coding and Reimbursment Supervisor had this list I'm not sure where it came from from but it is very helpful. I believe this is based off CMS.

    Short Cuts fot ROS:
    "Except as aboe, all other systems were reviewe and are negative."
    "All sysems are complete and negative."
    "No pertinent positives out of all systems reviewed"

    Short Cuts that do not meet criteria:
    "ROS is unremarkable."
    "the ROS is non-contributory"
    "ROS - negative"

    With what your doctor documented I would either query him to clarrify which systems he did review or not count it at all.
    Antoinette Milroy, CPC

  3. #3
    I would not give ROS for that statement. It does not reflect if any systems were addressed and how many, or all...???
    If on the other hand your provider would document that s/he reviewed the ROS as documented by someone else on a specific date and indicates where to find that document, then a ROS is possible based on the other document.

  4. #4
    North Carolina
    I agree with Karolina...unacceptable
    Rebecca CPC, CPMA, CEMC

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  5. #5
    I also agree with Karolina and Rebecca. Not acceptable. It is a good idea to create something that tells them what is acceptable verbiage (and what isn't) so they can get credit for doing it when they actually do it. Without that guideline, they may be doing an appropriate complete ROS but their statement isn't relaying that to you.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I, AAPC Fellow
    National Advisory Board Member 2018-2021, Region 6 Great Lakes
    Minneapolis AAPC Chapter, Education Officer 2018
    AHIMA ICD-10-CM/PCS Trainer
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