Review of Systems Statement

Would you give credit for a complete review of systems for the below statement?
A 14-point review of systems is complete, pertinent positives included in the HPI, otherwise review of systems negative.

Our current policy states that it must say "all others reviewed and are negative."

Comments

  • edited June 2017
    Yes, provided pertinent positives are mentioned in the HPI.
    They can get creative with language:)


    Wanda Torres, CCS-P, ACS-EM, AIHC ICD-10 CT
    Director of Physician Billing and Coding Compliance

    105 Raider Boulevard, Suite 101
    Hillsborough, NJ 08844
    908-281-0221 ext 116
    Fax: 908-281-0940
    Cell: 908-581-7128
    wtorres@idcare.com


  • edited June 2017
    I would recommend extreme caution if you're going to count that as complete. The requirements is a specified number of systems reviewed, not points. 14 points is not necessarily 14 systems.

    This is a 30 point ROS.
    No abdominal pain
    No depression
    No diarrhea
    No dizziness
    No dysphagia
    No heartburn
    No hoarseness
    No indigestion
    No loss of vision
    No tooth pain
    No nasal discharge
    No nausea
    No constipation
    No epistaxis
    No headache
    No hearing loss
    No sore throat
    No jaundice
    No otalgia
    No otorrhea
    No paresthesias
    No seizures
    No stool incontinence
    No suicidal ideation
    No syncope
    No tender gums
    No tinnitus
    No ulcers
    No vertigo
    No vomiting

    But it is only 5 systems.

    If they are going to document an "all others negative" statement is needs to include one of the following:
    "all systems
    "10 systems" (or more)
    "Compete ROS"

    Things like "otherwise negative" "negative except as documented" " the rest of the ROS is negative" and "10 point ROS is negative" have all failed to get past an auditor in payor audits.

    TT


    Todd Thomas, CPC, CCS-P ERcoder, Inc
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  • edited June 2017
    Right on Todd.


  • Thanks everyone I agree that it should be all others negative but had a few coders who disagreed.
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