Completing ROS

Hello all- When I am auditing a outpt office consult and I am counting up the ROS, say the DR bullets the ROS section and had GI, GU and cardio mentioned only. But in the History it states stuff regarding the patients respiratory, ENT and musculoskelatal section and in the Past Medical the doctor states catarac surgery in 2000.

So my question is...

The doctor would get credit for 7 systems for the ROS, correct?

GI, GU, Cardio, Resp, ENT, musculoskelatal, eyes (catarac surgery)

Ros

You can count an element discussed in the HPI as part of the ROS as long as you do not consider it in the counting for the HPI. So if the problem was chest pain, and she talked about the patient's shortness of breath, you could count that as ROS for respiratory if you do not use it in HPI as an associated symptom.

I retract my answer

It is OK to double dip! You can use an emement in the HPI to be counted in both HPI and ROS according to abundant references found at ercoder.com. They have CMS people saying that you can double dip on elements

Completing ROS

"Original Message: Hello all- When I am auditing a outpt office consult and I am counting up the ROS, say the DR bullets the ROS section and had GI, GU and cardio mentioned only. But in the History it states stuff regarding the patients respiratory, ENT and musculoskelatal section and in the Past Medical the doctor states catarac surgery in 2000.
So my question is...

The doctor would get credit for 7 systems for the ROS, correct?

GI, GU, Cardio, Resp, ENT, musculoskelatal, eyes (catarac surgery) "



No, not necessarily. You didn't clarify what "stuff" was documented in the history, although the cataract surgery would definitely be Past Medical History and not Review of Systems.

True, it doesn't always matter under which heading you find documentation, but past medical history is just that......... PRIOR illnesses, injuries, surgeries, hospitilazations, medications, allergies, etc. ROS is to further identify signs and symptoms that the patient may be experiencing or experienced either related to the CC and HPI or to identify other possible health issues. Think of ROS as "Review of SYMPTOMS" rather than "Review of Systems". If a patient comes in complaining of a pounding frontal headache and nausea for three days, the doctor is going to logically ask the patient about vomiting and probably other related symptoms like fever, blurred vision, dizziness, etc. Those things would be Review of Systems. (You already have the CC, location, quality, duration and associated SS in the HPI) If that patient then stated that they also have Hypertension and Diabetes, that is past medical history and would be counted there. The doctor may then go on to ask about other symptoms that might pertain to those conditions........ polydipsia, polyuria, heart palpitations, SOB, etc, and those would then go back up to ROS.

Does that help clarify it ??

Completing ROS

You can count ROS found anywhere in the history--HPI, ROS.

Eye: cataract surgery I would call past medical history. ROS for eye would be: no blurry vision, no visual problems, etc.

http://www.codapedia.com/~article_302_.cfm

http://www.codapedia.com/~article_87_Review%20of%20Systems.cfm

Ros

Thank you for your help!!! I just have to say that this website is amazing!! My questions seem so simple and once reading the responses that I'm given, I already knew the answers BUT it also helps with the education of my physicians!!! Thank you so much!!!