Results 1 to 3 of 3

Review of Systems - cheif complaint

  1. #1
    Location
    Springfield, Mo
    Posts
    382
    Default Review of Systems - cheif complaint
    Medical Coding Books
    Does a review of systems have to reflect the cheif complaint? I mean if the cc is "foot pain, bunion", does the ROS need to say Musculoskeletal: foot pain?? or bunion?? One of our doctors uses a questionaire to get the info for his ROS and if the patient does not answer YES to his specific questions, their ROS could show NEGATIVE for every system. Wouldn't that leave you wondering WHY they are here?
    Appreciate any thoughts.

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default Depends
    This depends on how your questionaire is worded and how the physician documents his/her review of that patient-completed information.

    It also depends on how your carrier considers "duplicating" this information from HPI and ROS.

    Some carriers want something OTHER than the HPI listed in the ROS ... could be same system but they want a different problem. For example: CC is bunion right foot
    ROS for musculoskeletal is negative for problems with gait or muscle weakness

    Some carriers will allow the positive finding for the CC to be also reflected in the ROS - for example: ROS all systems reviewed and negative except as noted in chief complaint and HPI.

    I know that's not the definitive answer you'd hoped for, but I hope it helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Location
    White Plains, NY
    Posts
    123
    Default
    As an auditor, if the CC contradicts the ROS, I question if any of the ROS was done at all. I have the same feeling if the Exam contradicts the ROS. Say the exam states SOB, rails, cough, but the ROS says Resp. system is normal - or "all systems normal."
    Especially in an EMR, I woder if any ROS was done at all.

    Of course, the rest of the record has to be taken into account, and E/M is notorious for its grey areas. Seeing a red flag does not necessarily mean the ROS should automatically be counted out.

    Lin
    CPC, CEMC, CPMA

Similar Threads

  1. Review of systems - help
    By Mama3beartn in forum Auditing General Discussion
    Replies: 4
    Last Post: 07-08-2014, 03:09 PM
  2. Review of Systems - brought study guide
    By Naveen Rachagolla in forum E/M
    Replies: 14
    Last Post: 01-09-2013, 01:23 AM
  3. Review of Systems - unable to obtain
    By skaur in forum E/M
    Replies: 4
    Last Post: 08-30-2012, 06:47 PM
  4. review of systems - past medical history
    By sgeroux in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 04-13-2009, 02:13 PM
  5. Review of Systems - exception of this line
    By ammontagano in forum E/M
    Replies: 4
    Last Post: 02-02-2009, 01:39 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.