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College of Medicine Office of Compliance, Gainesville, Florida
COMPLIANCE TIP -
Review of Systems (ROS) in Evaluation and Management servicesThe Review of Systems is an element within the history section of an Evaluation and Management service. Federal guidelines identify the systems as:
- Constitutional
- Eyes
- Ears/nose/mouth/throat
- Respiratory
- Allergy/immunizations
- Cardiology/vascular
- Psychiatric
- GI
- GU
- Musculoskeletal
- Neurological
- Endocrine
- Hematological/lymphatic
- Integumentary
Please note that ears/nose/mouth/throat comprise one group, and it is separate from eye.
A complete ROS (highest level) includes documentation on 10 or more systems; or alternatively, comments on some systems and the statement "all others negative". The alternative statement, "all others negative" is only appropriate when all 14 systems are reviewed.
TIP:
- The phrase "all others negative" when all 14 systems were reviewed can be useful.
- Phrasing such as, "a complete 12 system review of systems was performed" is NOT appropriate. (It is not possible to determine which 2 systems are missing). In an electronic record environment, using a smartphrase with inappropriate language can be detected with word search/data mining techniques. Please adhere to federal guidance when constructing smartphrases.
Any questions? The Office of Physician Billing Compliance contact information: (352)265-8359 or e-mail Nina Tarnuzzer (nwt@ufl.edu) or Susan Boyle (boylesa@ufl.edu).
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This page created October 12, 2010
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