tci General Surgery Coding Alert - 2017 Issue 4

Reader Question: Navigate "All Others Negative" ROS

Question: One of our surgeons tends to note “all others negative” in the electronic health record for his review of systems (ROS) part of the exam. Can we count this when we’re choosing the appropriate E/M code? SuperCoder Subscriber Answer: You may be able to find ROS elements in the history of present illness (HPI), but keep in mind that the physician must document at least one problem pertinent system with the “all others negative” statement. It’s actually up to the doctor to decide how many systems are pertinent to the complaint. Because the documentation...

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