Review of Systems

Can anyone tell me why or where to look to find the explanation of why you can't use the phrase Remaining ROS negative except as per HPI. Also how should it be phrased so that the provider can get credit for stating the rest of the review of systems is negative.

re: Review of Systems

This is a State by State interpretation of the Official Guidelines regarding ROS. CMS Guidelines state: "All other systems negative", once the presenting problems systems are inventoried will allow a complete ROS. Texas, for example, does not accept this statement and providers must list all systems inventoried, and medically necessary, individually. The first question is "was it medically necessary" to do a complete ROS based on the presenting problem(s). The second question is did the documentation support a complete ROS? You must follow State guidelines. CMS says "all other systems negative" is acceptable. The ROS or Review of Systems helps define the problem, clarify the differential diagnosis, identify needed testing through a series of questions seeking to identify symptoms the patient may be experiencing or may have experienced. Follow documentation guidelines, scoring, etc. for your local
carrier/Medicare Administrative Contractor (MAC).

re: Review of Systems

There is an article on Codapedia that might help:

http://codapedia.com/article_87_Review-of-Systems.cfm

Most (but not all) Medicare Contractors and private payers follow the Documentation Guidelines, as developed jointly by CMS and the AMA. So, check around on your MACs website and see what they say in their E/M guide. As Nancy said, some Contractors developed their own "interpretations."

Having said that, if the provider documents the positive AND pertinent negatives either in the HPI or ROS section, I credit, "Except as above, all other systems were reviewed and are negative."

Try to impress on the provider the distinction: it isn't that you don't have to ask all the systems, you don't have to individually LIST all negative systems. The provider still needs to ask them all to get credit.