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."
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
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
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
President 941 NW 164th, Suite 1
todd@ercoder.com Edmond, OK 73013
(405) 749-2633 www.ERcoder.com
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