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Thread: ROS documentation

  1. #1

    Cool ROS documentation

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    I have a physician who wants to dictate "10 point review of systems were obtained; negative other than above" in his hospital dictation. What do you think? Is this sufficient?

    Thanks

  2. #2

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    Quote Originally Posted by todd5400 View Post
    I have a physician who wants to dictate "10 point review of systems were obtained; negative other than above" in his hospital dictation. What do you think? Is this sufficient?

    Thanks
    My concern would be what other systems than above were obtained. Which are negative? I am not positive, but I don't think that would be suficient. If the doctor reviews all the systems, he might be able to state "all other systems reviewed and are negative, except for ones listed above". If you look under the 97 guidelines, it tells you
    "DG: at least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be INDIVIDUALLY DOCUMENATED. FOR THE REMAINING SYSTEMS, A NOTATION INDICATING ALL OTHER SYSTEMS ARE NEGATIVE IS PERMISSIBLE. In the absence of such a notation, at least ten systems must be individually documented."

    Hope this helps

  3. #3

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    I agree. The physician is not being clear and concise with his/her documentation. They should specifically document a response for each system or record "all systems negative".

  4. #4

    Default Ros

    Quote Originally Posted by codegirl0422 View Post
    My concern would be what other systems than above were obtained. Which are negative? I am not positive, but I don't think that would be suficient. If the doctor reviews all the systems, he might be able to state "all other systems reviewed and are negative, except for ones listed above". If you look under the 97 guidelines, it tells you
    "DG: at least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be INDIVIDUALLY DOCUMENATED. FOR THE REMAINING SYSTEMS, A NOTATION INDICATING ALL OTHER SYSTEMS ARE NEGATIVE IS PERMISSIBLE. In the absence of such a notation, at least ten systems must be individually documented."

    Hope this helps
    What if the physician notes diabetes, hypertension all other systems are negative and noted in the chart? Can we count this as 10 systems?

    Thank you!

  5. #5

    Default

    My take on it is that the diabetes and hypertension could be part of the PFSH or part of the presenting problem. That would leave all other negative which would count as complete system review or ten systems.

  6. #6

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    I agree with member7.

  7. #7
    Join Date
    Apr 2007
    Location
    Central Arkansas
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    Default

    Well to answer your question. Your doctor can review all system and document whatever he wants by making his dictation 5 pgs long. The key is that it was not medical necessity. Therefore, no insurance company is going to pay for services that are not medical necessity.

  8. #8
    Join Date
    Apr 2007
    Location
    Watertown, NY
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    108

    Default

    our docs do this too but they are required to state all others negitve this clears up the confusion
    so this is how they word it
    12 point ROS reviewed and are negatve except what is stated in the HPI.
    or 12 point ROS reviewed and negative unless stated otherwise in HPI
    we just went through a medicare audit and nothing was noted wrong with the statement.

  9. #9
    Join Date
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    Location
    Milwaukee
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    Smile

    My caution to the physician would be to refrain from using that statement for every patient. "Remaining review of systems negative" or "all other ROS negative" are being scrutinized more these days.

    I would not doubt it if that phrase is going to restricted for a complete 10 ROS in the future. It is similar to the wording "noncontributory" as being a no-no for PFSHx. I also agree with the coder who stated "medical necessity." Why would you need a complete ROS for a low level service? Again, using that phrase all the time would be a red flag.

    Just my 2 cents.
    E. Frohna
    Evangelina Frohna, CPC, CEMC

  10. #10
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    York, Pa
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    Quote Originally Posted by efrohna View Post
    My caution to the physician would be to refrain from using that statement for every patient. "Remaining review of systems negative" or "all other ROS negative" are being scrutinized more these days.

    I would not doubt it if that phrase is going to restricted for a complete 10 ROS in the future. It is similar to the wording "noncontributory" as being a no-no for PFSHx. I also agree with the coder who stated "medical necessity." Why would you need a complete ROS for a low level service? Again, using that phrase all the time would be a red flag.

    Just my 2 cents.
    E. Frohna

    I agree with you 100%, I think some physicians and maybe some coders get medical necessity and mdm mixed up or confused. I am always on the alert for Medical necessity when I am reviewing charts.

    Today I had a chart on a pt who has no underlying diseases and came in with sore throat and possible bronchitis that was billed as a 99214 that for me in this case made me put medical necessity into play...

    Just wanted to share
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

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