tci ED Coding & Reimbursement Alert - 2001 Issue 3

Reader Question: Review of Symptoms vs. Past Medical History

Question: When a physician lists an organ system and documents past medical/surgical history instead of current signs or symptoms, can this be used as review of systems (ROS)? Illinois SubscriberAnswer: In a word, no. Using past medical history terminology to code ROS, for example, skin: no history of melanoma, or genitourinary: no history of hysterectomy, or cardiovascular: no history of myocardial infarction, is incorrect coding because these are not ROS comments. Differentiate ROS documentation by looking at it as typically current information about systems. For example, the review of skin would be marked negative or no complaints of rash...

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