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Documenting ROS

  1. Default Documenting ROS
    Exam Training Packages
    Some of our ER Docs are using the statement "all relevant systems reviewed and all negative except for the above" as their documentation of the ROS.
    We are unsure if the word "relevant" would pertain to the exam as a whole or to the chief complaint of the patient. Would that be considered a full ROS or would the Doctor need to document the "relevant" systems that they reviewed?
    Thank you.

  2. #2
    Location
    Urbana, IL
    Posts
    23
    Default
    The term "relevant" leaves too much room for interpretation by insurance companies and external auditors and should not be recommended to capture a "full" or "14 system" review. I recommend questioning the providers how many systems they are reviewing and if they tell you they review all 14 systems advise them to discontinue the use of the term "relevant" based on my above statement. If they are not doing a full 14 point review then they should list out each along with the positives or negatives for each.

    I've also seen providers use the statement "essentially negative" and have had to educate them to discontinue in the manner explained above.

    Hope this helps! -Dawn
    Regards!
    Dawn Peterson
    Coding Consultant/Billing and Coding Instructor
    Illinois, USA

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default Problem Pertinent ROS
    At best I would give credit for a problem pertinent ROS which would limit them to a 99282.

    Would definitely NOT give credit for a full 14-point review of systems. If they are performing a completd ROS they need to document a complete ROS.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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