AAPC - Back to school
Results 1 to 3 of 3

Thread: Provider review of ROS and PFSH

  1. #1

    Default Provider review of ROS and PFSH

    AAPC: Back to School
    Per the CMS guidelines, the ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the
    information, there must be a notation supplementing or confirming the information recorded by others.

    Can someone tell me what exactly this notation has to say? Can it be something as simple as "ROS and PFSH reviewed?"

    Does the provider's signature at the end of the note fill the requirements of CMS in attestation? Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  2. #2
    Join Date
    Apr 2007

    Default Supplementing or Confirming

    there must be a notation supplementing or confirming the
    information recorded by others

    If it was documented by other staff, I would look to see if he added to it or wrote a statement such as "ROS positive for.."

    See also the following

    7. Providers are responsible for clearly identifying who performed each service documented within the note. When entering patient data into the medical record that the provider did not personally take or test, the provider must attribute the information to the person who did.
    8. If the provider references a form within the record (e.g., review of system form), he/she must reference the form with sufficient detail to uniquely identify the source. Example: “For review of systems see form dated 1/1/08.”
    Heather Winters, CPC, CFPC

  3. #3


    Thanks so much! This is helpful.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

Similar Threads

  1. Use of Allergy as PFSH or ROS
    By linc11 in forum E/M
    Replies: 4
    Last Post: 05-27-2016, 12:47 PM
  2. Review of PFSH/ROS
    By ajh165 in forum E/M
    Replies: 1
    Last Post: 11-19-2014, 03:54 AM
  3. ROS/PFSH question
    By AmandaW in forum E/M
    Replies: 4
    Last Post: 06-25-2014, 07:09 AM
  4. ROS and PFSH reviewed
    By wahmcoder in forum E/M
    Replies: 2
    Last Post: 12-21-2009, 10:44 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.