What Is a 12 Point Review of Systems

Published in the July 2013 issue of Today's Hospitalist

ARE YOUR BILLS Existence DOWNCODED by auditors or others reviewing them? Chances are the culprit is as well scanty documentation for the history and examination elements.

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Could using scribes decrease hospitalists' burden of documentation and streamline admissions and ED throughput?  Related article – Baronial 2019: Scribes help hospitalists with more than just documentation.

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Getting these elements right is a must to make certain that documentation supports the level of service that y'all bill. Here are a few questions from readers on guidelines for documenting history and exam, 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 trunk systems for our physical exam. In terms of what we document, how much do we need to include as specifics for each of these?

I've heard that nosotros can just document the main complaints and abnormalities, so note that the others in the 12-point ROS were negative. But I've also heard that we should have at to the lowest degree 3 negative findings documented in each system. And I have the same question for the physical exam: How many "normal" items do we need to document per organ organization to consider billing a comprehensive concrete?

The "Evaluation and Services Management" guide put out by 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 straight you to certificate 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 caution: When using the "all other systems reviewed and negative" statement, make sure yous're performing a x-plus organisation review. The statement is a documentation shortcut, not a performance ane, and physicians still demand to review at least 10 systems.

Likewise, your documentation should clearly communicate performing a "complete" review of systems. You tin can practice then with the "all other systems were reviewed and are negative" example or, as you stated in your question, "others in the 12-betoken ROS were negative."

Simply statements such equally "ROS negative" or "negative other than in the HPI" don't support performing a consummate ROS. If you don't use the "all other systems" statement, you must individually document findings for at least 10 systems.

As for the exam, the "Evaluation and Services Management" guide besides does not spell out a required number of normal or negative findings. The 1995 guidelines define comprehensive multisystem exam equally the exam of eight or more organ systems.

Here are a few quotes from the "Evaluation and Services Management" guide on examination points:

• "[S]pecific abnormal and relevant negative findings of the examination of the afflicted or symptomatic body area(s) or organ system(s) should be documented. A note of 'abnormal' without elaboration is non sufficient."
• "Abnormal or unexpected findings of the test of any asymptomatic torso area(s) or organ system(southward) should be described."
• "A brief statement or note indicating 'negative' or 'normal' is sufficient to document normal findings related to unaffected expanse(s) or asymptomatic organ arrangement(s)."

Some other tip to keep in mind to help clarify that last bespeak: Don't utilize a simple "negative" or "normal" statement as your but documentation of the examination for the system(s) related to the presenting problem. For instance, when examining a patient who presents with chest pain, don't document "Cardiovascular: negative." Instead, document specifics of that cardiovascular test, even if all your findings are negative.

Previously documented history
I work with a large hospitalist group and have used your column, "7 mistakes to avoid when billing subsequent visits" (September 2006). In that column, you country that providers can refer to previously documented history as long as they include the engagement 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 showtime time I've heard that doctors can update a previous HPI.

I should have been more specific. Clinicians can update only previously documented review of systems and by, family and social history. Doctors should specifically reference the engagement and location of the review of systems and by, family and social history being updated. They should then document any new bug or changes to that information or country that there are no changes.

Unresponsive patients
Say a patient is unresponsive or otherwise unable to provide the review of systems for the initial admission history and physical. How should we document that and then nosotros can bill a higher level than a level one initial hospital visit (99221-99223)? Do we have to document time spent? Or can nosotros pecker disquisitional care time if the patient's condition warrants it and the physician meets documentation guidelines of spending at least thirty minutes providing disquisitional intendance services? And what if the patient is demented and gives an inaccurate review of systems?
If yous aren't able to obtain a history from a patient or other source due to the patient'due south clinical condition "being intubated, comatose or mentally impaired, for instance "certificate the specific reason why yous could non accept a history. You should be able to receive credit for a comprehensive history in such situations, merely 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 result of Today'southward Hospitalist.

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Source: https://www.todayshospitalist.com/how-specific-does-your-documentation-need-to-be/

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