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Acceptable Verbiage for complete exam

  1. #1
    Santa Rosa
    Question Acceptable Verbiage for complete exam
    Medical Coding Books
    I was wondering if you knew the acceptable verbiage and/or terminology that is acceptable for a complete ROS and/or Phys. Exam.

    What I mean is for example the phrase, "all others reviewed and are negative".

    Are there actually a few "catch phrases" that will stand up to an audit?


  2. #2
    Tyler, Texas
    This verbiage will likely bear up for the ROS, but I would strongly suggest something like "A 14 point ROS was complted and the other areas are negative" at the end of the ROS documentation. It identifies the scope of work done more completely. The "all others negative" does not work for Physical exam in my experience. You need to specifically identify each area examined in order to get credit. You can't say "A comprehensive physical was done and except as noted was normal" and expect comprehensive credit.

  3. #3
    Concord, NC or Rochester, NY
    For the ROS - you have to review all pertinent systems that could be affected and then the statement: 'all other systems negative' is appropriate to provide a complete ROS. Do not use 'all other systems reviewed and negative' since the MD did not review them.

    For the exam, the Provider has to examine 8+ organ systems (note this does not include body areas) for 95 DG's.

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