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10 point review of systems

  1. Default 10 point review of systems
    Medical Coding Books
    our physicians use this statement for ROV:
    "10 point review of systems is otherwise negative except as mentioned above."

    Is this sufficient for a COMPLETE review of systems?

  2. #2
    Location
    Tacoma, WA
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    1,087
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    Quote Originally Posted by fpaisley View Post
    our physicians use this statement for ROV:
    "10 point review of systems is otherwise negative except as mentioned above."

    Is this sufficient for a COMPLETE review of systems?
    I don't believe that is enough to constitute a complete review of systems. Each system still needs to be referenced if they are negative and a note to that effect. The "10 point review of systems" leaves a lot up to interpretation vs having a specific note for the relevant systems.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. #3
    Location
    Concord, NC or Rochester, NY
    Posts
    154
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    I have the physicians document the systems that are +/-'ly impacted and then record - all other systems negative (which is allowed by 95 standards). They need to review the systems that could be impacted for the reason of the visit.

  4. #4
    Location
    North Carolina
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    3,126
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    Quote Originally Posted by fpaisley View Post
    our physicians use this statement for ROV:
    "10 point review of systems is otherwise negative except as mentioned above."

    Is this sufficient for a COMPLETE review of systems?
    No...

    "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."

    https://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp
    Rebecca CPC, CPMA, CEMC




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  5. #5
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    The reason why that phrase may not be acceptable is because there is so much variation between providers of different specialties regarding what systems are reviewed in a '10-point' ROS. CMS polled doctors across the country and found that different providers do different system reviews. So for an example, an ENT doctor in Boston may review 8 organ systems, while a OB/GYN in California may review 6 different ones, and an Oncologist in Texas may review 12. In that example, the ENT may say 'The remainder of the ROS was negative' but that does not earn them credit for a 'complete' ROS, because they only reviewed 8 and a 'complete' ROS is defined as 10+ systems.

    The best way to make sure that you get credit for a complete ROS is to use the word 'all' such as the phrases:
    "Patient has had some coughing and wheezing, no fever, no nausea, no vision changes. All other systems are negative."
    "Patient has limited range of motion in the knee, all other systems are reviewed and negative."

    Notice how those phrases both make it clear that ALL other systems are negative, while phrases like these leave some room for uncertainty:
    "Nausea and vomiting. Other systems negative." (how many other systems?)
    "A 10-point ROS was negative." (what 10 points? Can we be sure they didn't count Cardiovascular 2 or even 3 times?)
    "No chest pain or palpitations, no shortness of breath. ROS Otherwise negative." (We don't know what other systems were reviewed)
    "No fevers, chills, headaches, vision or hearing changes. Remainder of ROS is negative." (We can't be sure how many other systems were reviewed.)
    "Occasional headaches. Heartburn nightly. Otherwise no complaints." (This does not indicate what other systems were reviewed.)

    Those are some common examples that I see all the time, and I usually flag them to let the providers know that Medicare won't accept that as a complete ROS. For a new office patient, that could hold back the whole level of the code (since a level 4 or 5 new patient requires a Comprehensive level of history.)

    I hope that answers your question.
    Mike Enos, CPC, CPMA, CEMC
    Consultant, Chart Auditor, Instructor
    Enos Medical Coding
    Warwick, Rhode Island

  6. #6
    Default CMS Poll?
    Mike, do you have a link or reference for the poll conducted by CMS of providers across the country?

  7. Default Ros
    "All systems were reviewed and no abnormalities were found"
    Is this exceptable even though they do not state All systems are NEGATIVE?

  8. #8
    Location
    Moore Oklahoma
    Posts
    43
    Default
    Quote Originally Posted by remarti5210 View Post
    "All systems were reviewed and no abnormalities were found"
    Is this exceptable even though they do not state All systems are NEGATIVE?
    I wouldn't accept this statement if all systems were reviewed and no abnormalities found then why did the patient come in? Auditors want to see what was reviewed especially if it is pertinent to the reason the patient came in. If your provider uses an EMR they can adjust the template to make the ROS easier for the provider to capture what he did, auditors don't necessarily like the templated information but we have to count it. Mike also has some very good advice in his post.
    Last edited by mlbaker1974; 12-05-2013 at 03:18 PM. Reason: grammar
    Misty Baker, CPC
    Coding Compliance Specialist

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