Codapedia is now a division of Find-A-Code

Review of Systems

January 30th, 2015 - Codapedia Editor
Categories:   Audits/Auditing   Coding   Documentation Guidelines  
0 Votes - Sign in to vote or comment.

Sometimes one symptom can be used in more than one system.  For example, dizziness. Although we typically think of this as a neurological symptom, sometimes cardiologists ask about dizziness and relate it to the cardiovascular system. 

In the citations section of this entry, there are references for symptoms that go with each system in the review of systems. 

Can you use an item, which you have counted in your history of the present illness in your review of system as well?  That is, can you double-dip?  There is nothing in the Documentation Guidelines themselves which prevents you from double-dipping.  That is, if a patient describes in detail their GI complaint and it is documented as a history of the present illness, you may count that as a GI ROS in that section of the notes.  Some consultants and auditors don't allow this.  There is no CMS guideline that prohibits it. 

A staff member may complete the review of systems or the patient may complete this ROS on a form, and it can count towards the level of service for the note, as long as there is evidence that the billing clinician has reviewed this information.  This might be shown by the billing clinician reviewing the form, making comments, and signing and dating the form.  Or, the clinician should add to the documentation “the remainder of the review of system is on the history and was reviewed with the patient by me.”

Can we use the words “all others negative” in the review of systems?  The guidelines are specific about this.  After the billing clinician has documented all the positives in the history of the present illness and any pertinent negatives relating to the patient's presenting problem or condition, then the clinician, after reviewing all of the systems, may say, "Except as above, all others were reviewed and are negative."  Let's examine that statement more carefully.  First, all the positives must be documented.  Second, all of the negative systems specifically related to the patient's presenting problem or condition must be specifically noted to be negative.  The billing clinician must review all of the systems in the review of systems.  Then, it is permissible for the billing clinician to say, “Except as above, all others were negative,” and this will count as a complete review of systems. 

What about the words noncontributory or unremarkable?  The guidelines do not specifically mention these words.  Most auditors do not count them as a complete review of systems.  Some carriers have specifically stated that they are not countable for a complete review of systems.  Stick with negative!


Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

Q/A: How Many Diagnosis Codes do I use?
April 15th, 2019 - Wyn Staheli, Director of Research
Question: My patient has a lot of chronic conditions. Do I need to include all these on the claim? I know that I can have up to 12 diagnoses codes on a single claim. What if I need more than that? Answer: More is not always better. You only need to ...
Watch out for People-Related ‘Gotchas’
April 15th, 2019 - Wyn Staheli, Director of Research
In Chapter 3 — Compliance of the ChiroCode DeskBook, we warn about the dangers of disgruntled people (pages 172-173). Even if we think that we are a wonderful healthcare provider and office, there are those individuals who can and will create problems. As frustrating as it may be, there are ...
Q/A: What do I do When a Medicare Patient Refuses to Sign an ABN?
April 8th, 2019 - Wyn Staheli, Director of Research
Question: What do I do when a Medicare patient refuses to sign an ABN? Answer: That depends on whether the patient is still demanding to have/receive the service/supply. If they aren’t demanding the service, then there is no need to force the issue. Just make sure that you still have an ...
Prepayment Review Battle Plan
April 8th, 2019 - Wyn Staheli, Director of Research
Any type of payer review can create some headaches for providers and cause problems for a healthcare office. Even for a practice that has taken administrative steps to try and prevent a prepayment review, it can still happen. A prepayment review means that you must include documentation WITH your claim. ...
Looking Ahead - Changes in Dentistry!
April 3rd, 2019 - Christine Taxin
In the next 10 years, what is the biggest change dentistry will experience? FW: We all know healthcare in the U.S. is changing rapidly. Dentistry is no exception. My opinion is that several big changes are forthcoming. Most often, I think about changes that benefit patients and/or providers. Here are three ...
Q/A: I Submitted a Claim to the VA and it’s Being Denied. Why?
April 1st, 2019 - Wyn Staheli, Director of Research
I submitted a claim to the VA and it’s being denied. Why? There are several reasons why your claim might be denied by the Veterans Administration (VA). However, without more information about the claim itself (e.g., services billed), we can only provide the following general information about the VA and chiropractic ...
Corrections and Updates
April 1st, 2019 - Wyn Staheli, Director of Research
One constant in our industry is change. Policies change, contracts change, and there are updates. Also, people aren’t perfect and mistakes can be made. So this article will cover a variety of topics. Published Articles We appreciate feedback from our valued customers. We have received feedback regarding two of our articles which ...

About Codapedia & Find-A-Code Contact Us Terms of Use Privacy Policy Advertise with Us

Codapedia™/Find-A-Code™ - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain) - Fax (801) 770-4428

Copyright © 2009-2019 Find A Code, LLC - CPT® copyright American Medical Association