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Review of Systems

Annie Posted Fri 25th of April, 2014 09:49:14 AM

If a provider writes for his ROS: a detailed review of systems was obtained and mainly postive as described in the HPI..... Would this be acceptable to give him a complete ROS without his stating the actual number?

Also how would you level it if the provider states could not obtain as the patient is intubated.

SuperCoder Answered Tue 29th of April, 2014 12:20:59 PM

This is not an acceptable statement. Medicare Contractors have variability on how they credit ROS. Most Contractors accept a statement which implies that “all other systems are negative.” In order to use this statement, you have to ask the patient about all systems (as identified in the Documentation Guidelines) and document a specific reference to any positive findings, and pertinent negative findings. Other Contractors who do not accept the generalized comment require individual comments for each of the system; and a minimum of ten individually documented systems equates to a complete ROS. You must check your Contractor rules to determine which method is approved for your geographical area.

Most Contractors credit a complete ROS for not being able to obtain the information directly from the patient. In order to receive credit, the physician must attempt to obtain the information from other sources (eg, chart, staff, family) and document the attempt along with a comment that the remainder of the ROS cannot be obtained due to …..(indicate reason).

Thanks.

Annie Posted Tue 29th of April, 2014 15:05:55 PM

So if the provider indicates reason why he cant then I would give him credit as complete ROS or Detailed.

SuperCoder Answered Wed 30th of April, 2014 10:01:28 AM

Most Contractors credit a complete ROS for not being able to obtain the information directly from the patient. In order to receive credit, the physician must attempt to obtain the information from other sources (eg, chart, staff, family) and document the attempt along with a comment that the remainder of the ROS cannot be obtained due to …..(indicate reason).

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