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Review of Systems – Documentation for Complete ROS

Guidelines say: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation of indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.

There are 14 possible systems to be reviewed. Does this statement mean that to get credit for a complete ROS you have to individually document the 10 systems and then all remaining (4) can be documented as "all other systems negative)?

I have always allowed my providers to document the pertinent +/- (however many that may be) and then state "all other systems negative" to get credit for a complete ROS. A coder on our team is reading the guidelines differently so we thought we’d see how others interpret this.

Thank you,

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