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Review of Systems

  1. #1
    Default Review of Systems
    Medical Coding Books
    Is the review of systems a required component of the history for an established visit? Where can I find documentation that states this? Also when documenting for time is the term "patient education" a substantial enough explanation?
    Kimm Hall CPC, CMSCS, CGCS

    If you live to regret then you have not learned lifes lessons.

  2. Default
    Established visits are scored on two of three elements. And so, a ROS is not an absolute requirement. It is possible to score based on the level of Exam and the level of the Medical Decision Making, if the History doesn't support the level.

    It is, however, good practice, in most cases, to document a Review of Systems, for at least the system wherein the patient's complaint(s) are found.

    In my experience, the ROS questions are generally asked, but may not be documented if the provider doesn't find the answers to his/her questions to be significant. But, they should document, for lots of reasons, that the questions were asked, and how they were answered.

  3. #3
    The same components are always required to determine your level of history.

    You don't have to do a ROS but that limits you to a problem focused history.

    The only difference between an established pt vs a new or consult is you only need 2 of 3 not 3 of 3.

    So if history is your lowest level b/c no ROS you don't have to consider it at all and just used exam and mdm to level your service.

    Laura, CPC

  4. #4
    Thank you so much for your replies and input. Do you all have any input on the other question about time? I know that it has to be stated that more than 50% of the time was spent in counseling and/or coordination of care and what was done during that time must be stated; but, the question is whether or not the words "patient education" will suffice as an explanation or should there be a more explanatory statement?

    Thanks for your input
    Kimm Hall CPC, CMSCS, CGCS

    If you live to regret then you have not learned lifes lessons.

  5. #5
    I prefer to see a bit more elaboration as to the content of the patient education. For example, your provider could state that they talked about a medication xyz and the associated side effect profile, what the benefit would be etc. It doesn't have to be a novel, but just a little bit of substance. Ask youself: if your payer were to audit the documentation, would they accept it?
    Karolina, CPC, CPMA, CEMC

  6. #6
    I'm sorry, I completely overlooked the time piece of the question.

    I agree with Karoline that there needs to be more than just patient education. They need to give a summary of what was discussed.

    Laura, CPC

  7. #7
    Thank you both for your responses. You have been extremely helpful
    Kimm Hall CPC, CMSCS, CGCS

    If you live to regret then you have not learned lifes lessons.

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