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Review of Systems documentation

  1. #1
    Question Review of Systems documentation
    Medical Coding Books
    Would the following Review of Systems count as a complete ROS:

    Review of Systems: Including General, Skin, HEENT, Endocrine, Respiratory, Cardiovascular, GI, GU, CNS, Musculoskeletal, Blood/Lymphatics, Mood/Affect, no other related symptoms are being reported. It is also worth noting that her daughter filled out the patient's questionnaire and answered yes on a lot of things; patient then stated no for a lot of those items. She states that her wieght went down approximately 20 pounds during/after surgery.

    This is the first time I have had a ROS documented like this and not real sure about it.

    Thanks for any feedback.

  2. #2
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    Quote Originally Posted by amymorgan View Post
    Would the following Review of Systems count as a complete ROS:

    Review of Systems: Including General, Skin, HEENT, Endocrine, Respiratory, Cardiovascular, GI, GU, CNS, Musculoskeletal, Blood/Lymphatics, Mood/Affect, no other related symptoms are being reported. It is also worth noting that her daughter filled out the patient's questionnaire and answered yes on a lot of things; patient then stated no for a lot of those items. She states that her wieght went down approximately 20 pounds during/after surgery.

    This is the first time I have had a ROS documented like this and not real sure about it.

    Thanks for any feedback.
    "It is also worth noting that her daughter filled out the patient's questionnaire and answered yes on a lot of things"-Yes to what?

    Personally, I would not credit this statement. It's too vague.

  3. Default
    you need to obtain a copy of the form that was completed in order to give appropriate credit to the systems. Don't be afraid to ask for it as if this was an external audit, the provider would have to provide it to support his coding.
    Danielle Carroll, CPC
    Last edited by nuenz@yahoo.com; 07-22-2010 at 11:06 PM. Reason: added name

  4. Default Can a Physician go back and amend his ROS to state that all 10 ROS complete?
    Can a Physician go back and amend his ROS to state that all 10 ROS complete?



    Quote Originally Posted by akmorgan View Post
    Would the following Review of Systems count as a complete ROS:

    Review of Systems: Including General, Skin, HEENT, Endocrine, Respiratory, Cardiovascular, GI, GU, CNS, Musculoskeletal, Blood/Lymphatics, Mood/Affect, no other related symptoms are being reported. It is also worth noting that her daughter filled out the patient's questionnaire and answered yes on a lot of things; patient then stated no for a lot of those items. She states that her wieght went down approximately 20 pounds during/after surgery.

    This is the first time I have had a ROS documented like this and not real sure about it.

    Thanks for any feedback.

  5. Default
    According to CMS 1997 E/M Guidelines

    A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI, plus all additional body systems.

    DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented.
    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.


    Page 8. Source

    https://www.cms.gov/Outreach-and-Edu...guidelines.pdf


    I would not give credit to the original poster's statement. You see the systems listed. However, you don't know what questions were asked and if there were positive responses or pertinent negatives... too vague.
    Karl M. Ellzey, BAE, CDC, President
    Ellzey Coding Solutions and DermCoder.com online coding tools

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