ROS on hand written office notes

How often should a physician be updating the ROS on established patients. Once the ROS is done at the initial visit some physicians just reference the date and state no changes. I feel this should be done at least every 6 months if not every visit. Also, if the physician just draws a line down the boxes by each organ system on the exam should that be counted as documentation to support the E/M level billed.



Thanks!

ROS on handwritten office notes

The ROS needs to be REVIEWED with the patient, and updated, in order to count it today. "Are you still feeling short of breath?" "Any symptoms of depression or anxiety."

Remember, though, that if the provider is billing a 99213, only one system is needed in the ROS. If the provider is billing a 99214, only two systems are needed. They often document that in the HPI as they are taking the patient's history.

It is a liability issue, as well. If they didn't re-ask the questions, and the patient's status has changed--do they really want to sign off on that?

Ros

Have you ever heard of this in regards to ROS? Our "auditor" told us that if there is no ROS listed, that you can use the PM&SH. For example, she used DM to count as endocrine and history of hernia to count as GI. By doing this, she now counted two for the ROS. I have never heard of this but she said it is a Medicare rule. I think that it is fradulent since you can up the E/M level by doing this.