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Thread: Review of systems

  1. #1
    Join Date
    Apr 2007

    Default Review of systems

    AAPC: Back to School
    Re: Ros
    i have a fellow coder who has ask me the question if a dr. Gives a ros in the hpi and doesn't use it as part of the hpi can she use it. I said yes as long as she doesn't double dip. Further he states on the ros: Unremarkable, i have told her that i would not give him credit for that statement and that he should give at least one ros pertaining to the problem stated in hpi and then if done can state all other systems negative.

  2. #2
    Join Date
    Apr 2007


    That is correct, as long as you don't double dip it doesn't matter where the ROS is located (in the HPI or by itself) you can use it.

    Unremarkable does not get credit when I audit either.

    Laura, CPC, CEMC

  3. #3


    Remember the ROS is an expansion on the HPI asked by a series of questions by the provider.

    I often times see something like "patient complains of ear pain, fever, and nasal congestion"

    Ear would get location, fever associated signs and symptoms. and then nasal congestion would be a ROS for ENT. This is incorrect.

    The correct audit would be location ear, fever & nasal congestion as associated signs/symptoms.

    Hope that makes sense.

  4. #4
    Join Date
    Apr 2007
    North Carolina


    I agree with Laura. Unless your carrier specifically states that you cannot extract the ROS from the HPI, then I am comfortable doing so. There are carriers that do allow this concept.

    Q-Can a physician count a single history item in both the HPI and ROS? For example, could we count "shortness of breath" as an associated sign and symptom in the HPI and respiratory system in the ROS?
    A- A clearly documented medical record would prevent the need to "double-dip" for HPI and ROS, but WPS Medicare, in rare circumstances, could accept counting one statement in both areas if necessary.


    I don't necessarily like the "single history item", but you can see that it could be acceptable in certain situations.

    Also.....Dr. McCann's response (HCFA)

    The Medical Director responded with:
    "It is not necessary to mention an item of history twice in order to meet the guidelines for Review of Systems. Repetition of information or data is not required as long as it is appropriately referred to. Once should be enough."
    - John H. Lindberg, MD

    When he received the above response he then sent the same letter to HCFA with the response from his local carrier for Dr. McCann's opinion (who is supposedly the source of the double dipping rule). Dr. McCann's response was:

    "We agree with Dr. Lindberg that it is not necessary to mention an item of history twice in order to meet the Documentation Guidelines requirements for the ROS. It is important that the information which is provided can be inferred accurately and appropriately by a reviewer to determine level of service and medical necessity."
    - Barton C. McCann, MD


    Again...I think it boils down to responsible documenation, coding and compliance within your own carrier.

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