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ROS-all systems negative

  1. #11
    Location
    North Carolina
    Posts
    3,126
    Default
    Medical Coding Books
    Quote:It is a complete review of systems. When I was preparing for the CEMC exam last fall the practicum exam had this same scenario and the rationale was if it is documented all system are negative then it is counted as a complete ROS.

    Diane Bazuin, CPC, CEMC



    How is it that someone presents to the ER with no complaints? The poster stated that there wasn't anything to pull from the HPI. I find a compliance issue with this. This appears to be a fast track way of documenting without providing information about the nature of the presenting problem.

  2. #12
    Location
    Daytona Beach, FL
    Posts
    752
    Default Poor documentation!
    Quote Originally Posted by RebeccaWoodward* View Post

    How is it that someone presents to the ER with no complaints? The poster stated that there wasn't anything to pull from the HPI. I find a compliance issue with this. This appears to be a fast track way of documenting without providing information about the nature of the presenting problem.
    I agree with Rebecca in this scenario. Something is missing from this documentation if nothing can be found in the HPI and the documentation states ALL systems negative. The patient is in the ER so it isn't a routine visit - something has to be a positive somewhere! By just checking one box that says all systems negative, it seems that the provider is just being lazy in completing his documentation. In this case I would not award them with a complete ROS. I find it hard to believe that nothing was reveiwed for the HPI during this encounter or that all was negative! Why was this patient in the ER??

    In our Urgent Care we have a template for the doctors to follow - but each system has to be either checked with a positive item or checked as negative. This eliminates the ability for the doctor to be lazy and just check one box!

    Thanks,
    Jodi Dibble, CPC

  3. Default
    Quote Originally Posted by littlebit29 View Post
    According to the other posts in the forums alot of ppl are saying that this is not a complete ros when the only thing that is checked marked is the box. I looked online at other sites and I also looked in the AAPC study guide and it all states :
    E/M University Coding Tip: When documenting the ROS , it is not necessary to list each system individually. It is acceptable to document a few pertinent positive or negative findings and then say: “All other systems were reviewed and are negative.” in the aapc book its states that a complete ros is the positive and negative responses for all additional body systems related to the problem at least 10 systems must be noted.

    </EM>So now i am getting confused because alot of the other posts say you cant count the box as complete ROS and now i am being told it is a complete ros??? So how do i calculate this when it is just the box that is checked marked and i cant pull any information from the hpi??oh and this is for the ER E&M codes 99281-99285.
    Okay for an ER visit, you have to have at least one positive... I mean the patient came in for a reason. So in this scenario, I would say no ROS were done/documented. You cannot just check the box to check the box. However, if the patient was coming in say for a yearly exam, I can see the box being checked if the patient did not have any complaints. Hope this makes sense.

  4. #14
    Default
    I would have to agree with Pam, all others negative should not be used routinely and there should be some documentation of the CC and a correlating HPI/ROS documentation pertaining to such.

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