There are many talented and experienced coders who post on this board, and I have off-line discussions with several of them quite frequently. That having been said, there are a number of posts from coders who tell us, "this is what I do". As a professional coder, it is your reponsibility to research the documentation guidelines and use them as the basis for your standardized coding process. Consultants and other coders may certainly give their opinions, but the DGs really must take precedence. E&M University (Peter Jensen...and I talk to him all the time) is a consultant who provides recommendations. The AAPC study guide is just that....a guide. And even years ago, when I took the CPC exam, it was a known fact that CMS and the AAPC coding guides didn't necessarily agree...but the AAPC won't fine you if you make a coding error. I recommend you use only regulatory guidance to support your coding policy, not just comments from this board. The best responses you'll get from this discussion board are the ones that point you directly to the regulatory guidance. This is from the 1995 CMS guidelines:
Originally Posted by littlebit29
A complete ROS inquires about the system(s) directly related to the problem(s) identified in theHPI 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
What this tells us that simply checking off 'all others negative' is inappropriate, because CMS requires us to document pertinent positives and negatives. Exclusion of this documentation constitutes no system review.
Pam Brooks, MHA, CPC, PCS, COC
Dover, NH 03820
If you can dream it, you can do it. Walt Disney