Review of Systems

January 30th, 2015 - Codapedia Editor
Categories:   Audits/Auditing   Coding   Documentation Guidelines  
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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!


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