can a physician just use a blanket statement of All other systems reviewed/neg:YES" and not complete any of the ROS on a patient? I was under the impression that they had to complete the ROS that was pertinent to the issue in the HPI. I know I can pull some things from the HPI but they don’t always give a lot of information there.

The physician is telling me this: There are other facilities and ED staffing companies that routinely use this statement to indicate that a 10-point ROS has been completed and bill as such. In addition, it is my understanding that ROS may be extracted from the HPI as documented.

Can anyone provide me with some guidelines or documentation verifying the physician needs to document more than All other systems reviewed/neg:YES?

Review of Systems
Review of Systems
All other systems reviewed/neg: Yes

Thank you so much!