Results 1 to 3 of 3

Review of Systems in Newborns

  1. #1
    Question Review of Systems in Newborns
    Medical Coding Books

    The following questions were posed by one of my clients - does anyone have the answer? My first instinct is to give the 10 pt ROS, as one would do for someone who is untubated or comatose. Also, for past medical history - would you give the pre-natal details or affirm that the child was just - born!
    Many thanks -

    1. With a newborn (age 28 days or less), what is required for documentation of the review of systems (ROS)?

    2. More specifically for a high level admission (99223), does the MD need to document negatives and pertinent positives for 10 of 14 systems in a newborn?

    3. If a re-admission is done, say, the kid goes home for 10 days then needs to be readmitted, does a new ROS need to be done or can they refer to the previous ROS and note any interval changes?

  2. #2
    Milwaukee WI
    Default The rules stay the same
    To answer questions 1 & 2: There is no difference in the rules for meeting the key elements of ROS regardless of age of patient. So you need 10+ ROS for the highest level of service.

    However, you can state that there is no ROS and give a reason. We ask our neonatologists who see the baby at birth to state something along the lines of: "Other than HPI, ROS is negative for this neonate on first day of life."
    For Medical history we ask them to give the birth history.

    As for re-admission ... you can always refer to records in the chart, as long as you clearly identify the records, that you reviewed them, when you reviewed them, and any pertinent changes. For example:
    "Please see admission H&P dated mm/dd/yy, which I reviewed today; the only change is GI positive for diarrhea."

    F Tessa Bartels, CPC, CPC-E/M
    Last edited by FTessaBartels; 09-30-2008 at 01:11 PM.

  3. #3
    Thanks, Tessa!

    That's very concrete advice, since in the 1995 and 1997 guidelines, it just says:

    "For certain groups of patients, the recorded information may vary slightly from that described here. Specifically, the medical records of infants, children,adolescents and pregnant women may have additional or modified informationrecorded in each history and examination area.

    As an example, newborn records may include under history of the present illness (HPI) the details of mother's pregnancy and the infant's status at birth; social history will focus on family structure; family history will focus on congenital anomalies and hereditary disorders in the family. In addition, information on growth and development and/or nutrition will be recorded. Although not specifically defined in these documentation guidelines, these patient group variations on history and examination are appropriate."

Similar Threads

  1. review of systems - enlarged lymph nodes
    By VRcoder29 in forum Auditing General Discussion
    Replies: 1
    Last Post: 05-08-2015, 06:24 PM
  2. Review of Systems help!!
    By mdwyer in forum E/M
    Replies: 5
    Last Post: 03-20-2014, 12:14 PM
  3. Review of Systems - unable to obtain
    By skaur in forum E/M
    Replies: 4
    Last Post: 08-30-2012, 05:47 PM
  4. Review of Systems - cheif complaint
    By solocoder in forum E/M
    Replies: 2
    Last Post: 02-22-2012, 10:07 AM
  5. Review of systems- have a fellow
    By vcorso in forum E/M
    Replies: 3
    Last Post: 09-02-2009, 07:29 AM

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?


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.