What Is a 14 Point Review of Systems?
Published in the July 2013 consequence of Today's Hospitalist
ARE YOUR BILLS BEING DOWNCODED by auditors or others reviewing them? Chances are the culprit is likewise scanty documentation for the history and examination elements.
Could using scribes decrease hospitalists' brunt of documentation and streamline admissions and ED throughput? Related article – August 2019: Scribes help hospitalists with more than just documentation.
Getting these elements right is a must to brand sure that documentation supports the level of service that you pecker. Here are a few questions from readers on guidelines for documenting history and examination, and some answers.
ROS and exam specifics
We use a template for our preoperative consults that covers the 12 systems for our review of systems (ROS) and all body systems for our physical examination. In terms of what we certificate, how much practise nosotros need to include as specifics for each of these?
I've heard that we can just document the primary complaints and abnormalities, and so note that the others in the 12-bespeak ROS were negative. Simply I've as well heard that we should have at least three negative findings documented in each system. And I have the same question for the concrete exam: How many "normal" items exercise we demand to document per organ system to consider billing a comprehensive physical?
The "Evaluation and Services Management" guide put out past the Centers for Medicare and Medicaid Services (CMS) does not give a required number of negatives per system that you need to certificate. Instead, the guidelines direct you to document all positive and pertinent negative responses for the review of systems.
Statements such as "ROS negative" or "negative other than in the HPI" don't support performing a consummate ROS.
It is still acceptable to use the statement, "All other systems were reviewed and are negative." But a word of circumspection: When using the "all other systems reviewed and negative" statement, make sure you're performing a 10-plus system review. The statement is a documentation shortcut, not a performance i, and physicians still need to review at least x systems.
Also, your documentation should conspicuously communicate performing a "complete" review of systems. You tin do so with the "all other systems were reviewed and are negative" example or, as y'all stated in your question, "others in the 12-indicate ROS were negative."
But statements such as "ROS negative" or "negative other than in the HPI" don't support performing a complete ROS. If you don't use the "all other systems" statement, yous must individually certificate findings for at least 10 systems.
As for the exam, the "Evaluation and Services Direction" guide likewise does non spell out a required number of normal or negative findings. The 1995 guidelines define comprehensive multisystem exam as the exam of viii or more organ systems.
Hither are a few quotes from the "Evaluation and Services Direction" guide on exam points:
- "[S]pecific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ organization(south) should exist documented. A notation of 'abnormal' without elaboration is not sufficient."
- "Abnormal or unexpected findings of the examination of any asymptomatic trunk area(s) or organ system(s) should be described."
- "A cursory statement or notation indicating 'negative' or 'normal' is sufficient to document normal findings related to unaffected area(southward) or asymptomatic organ system(s)."
Another tip to keep in mind to aid clarify that final indicate: Don't employ a simple "negative" or "normal" argument as your just documentation of the exam for the system(southward) related to the presenting problem. For case, when examining a patient who presents with breast hurting, don't document "Cardiovascular: negative." Instead, document specifics of that cardiovascular exam, fifty-fifty if all your findings are negative.
Previously documented history
I work with a large hospitalist group and have used your column, "Seven mistakes to avert when billing subsequent visits" (September 2006). In that column, you country that providers can refer to previously documented history equally long as they include the date the previous history was taken and give an update.
Did you mean to include the history of the present illness (HPI) in that statement? This is the commencement fourth dimension I've heard that doctors can update a previous HPI.
I should have been more specific. Clinicians can update just previously documented review of systems and by, family and social history. Doctors should specifically reference the date and location of the review of systems and past, family unit and social history beingness updated. They should then document whatsoever new problems or changes to that data or state that there are no changes.
Unresponsive patients
Say a patient is unresponsive or otherwise unable to provide the review of systems for the initial access history and physical. How should we document that then we can beak a higher level than a level one initial hospital visit (99221-99223)? Exercise we accept to document time spent? Or can we nib critical care fourth dimension if the patient'southward status warrants it and the physician meets documentation guidelines of spending at to the lowest degree 30 minutes providing critical care services? And what if the patient is demented and gives an inaccurate review of systems?
If you aren't able to obtain a history from a patient or other source due to the patient's clinical condition "being intubated, comatose or mentally impaired, for example "document the specific reason why you lot could not accept a history. You should be able to receive credit for a comprehensive history in such situations, but yous may desire to confirm that with your carrier.
Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at kristywelker@hotmail.com. We'll try to respond your questions in a future issue of Today's Hospitalist.
Source: https://www.todayshospitalist.com/how-specific-does-your-documentation-need-to-be/
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