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  1. #1
    Default Ros
    Clearnace Sale

    We have a new pulmonologist, who specializes in sleep studies. I've been auditing a couple office visits and consults prior to it getting billed and I'm noticing that when he is documenting his HPI, he tends to state all other 10 point review of systems are negative, but doesn't actually break them down. Is this acceptable?

    Here is an example:

    Reason(s) for Visit:
    1. sleep study follow up - AHI of 0. Primary snoring. significant daytime fatigue. Poor sleep efficiency (40.5%). PLM's 47/hr causing arousals.

    Difficulty initiating and maintaining sleep. Severe knee pain and carpal tunnel pain. Very active mind at bedtime. Makes lists at night. No lights. No television. Does not face clock. Only caffeine in morning is a cup of coffee. On Prilosec for GERD. Has post nasal drip at night. When she cannot fall asleep in 30-45 minutes she reads a book (sometimes leaves room and other times stays in bed). Goes to bed at 11:30. Wakes up at 6:30. Wakes up 3 times a night. Has pain when she wakes up.

    All other 10 pt review of systems negative.

    The doctor then does have a thorough, PFSH, physical exam and assessment plan. My confusion is that the ROS are not broken down at all and just merely stated in the reason for visit. How can I take that into consideration when auditing his consults??


  2. #2
    Default Ros
    According to the 95 guidelines:
    A Complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

    Documentation Guideline: 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.

    Does this help?

  3. #3
    Milwaukee WI
    Default Which 10 points?
    Many auditors would NOT accept this documentation because we don't know which 10 systems he actually reviewed. He does enumerate 5 systems in the narrative sample you included (neuro, psych, musculoskeletal, ENT, GI).

    There are only 14 systems, so if he's not counting psych ("very active mind"), I guess he would have "10 other systems" that could be negative.

    If the patient is completing a history questionnaire, then the physician could use a statement such as: "Remainder of the ROS is negative, as per the patient questionnaire completed and reviewed by me today."

    Trailblazer has already indicated that they won't accept the "Other systems negative" statement, but want each system enumerated, positive or negative.

    I suspect that this standard is going to expand to other carriers.

    F Tessa Bartels, CPC, CPC-E/M

  4. #4
    Thanks to the both of you. Very helpful.

    I figured as much and I was concerned that none of the systems really seem to be broken down as the physical exam section was. I'm sure we'll be sitting w/ the doc sometime in the near future.

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