tci ED Coding & Reimbursement Alert - 2011 Issue 3

Reader Questions: Provide Proper Documentation to Make ROS Rock-Solid

Question: Encounter notes indicate a patient presented to the ED following a collapse and blackout; the patient had reported having chest pain 5 minutes before the blackout. During the review of systems (ROS), the physician gets positive responses when she asks the patient about head pain, dizziness, chest pain, muscle pain, and breathing trouble. The patient also had several nicks and cuts incurred from the fall that the physician asked about. Then, the physician wrote "Review of all other systems negative." Does this qualify for a complete ROS?Missouri SubscriberAnswer: You should be able to report a complete...

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