The review of systems (ROS) is the long series of questions patients are asked during a face-to-face physician or nurse encounter. Sometimes, these questions are provided in questionnaire form. The form may contain a statement such as, "Have you experienced any of the following" and then list a bunch of signs or symptoms for you to circle. Other times the physician may ask a rapid fire series of yes and no questions to try and discover any complaints you may or may not have. This is your review of systems. Look for this process the next time you see your physician.
If that form contains at least 10 organs or systems or if your physician touches at least ten systems in their series of questions, that is considered a complete review of systems and that level of documentation supports the highest level of E/M service your physician can bill for that visit. In other words, obtaining a review of systems is a mandatory component of documentation for most office or hospital face-to-face visits and having that form filled out or subjecting you to that series of questions is a required component to bill at highest level of documentation under Medicare rules.
There are two extreme spectrums in the ROS documentation process. At one end, some patients are unable to provide a ROS because of their underlying acute and or chronic medical conditions. Patients with dementia or delirium are often unable to provide input on their ROS. Some Medicare carriers allow physicians to document ROS not obtainable and receive credit for the highest level of ROS service, as long as documentation supports the reasoning and reasonable attempts are made to document available collateral information.
At the other end of the spectrum is the patient with the pan positive review of systems. This is the patient that answers yes to all ROS questions no matter what the question is. These patients can be painfully difficult to complete the history and physical process. Sometimes I will throw in an impossible symptom I make up that I know to be physiologically impossible just to see if the answer to my question is yes or no.
Pan positive ROS patients can be difficult to manage. They often have comorbid psychiatric conditions and or personality disorders that can make communicating like adults nearly impossible. They can be rude, demanding and manipulative. They can lead to great work place stress for the doctors and nurses taking care of their every catered need.
I have found doctors and nurses all have their own coping mechanisms for handling the pan positive ROS patient. Some doctors and nurses feel pity. Some feel numb. Some go on extra long lunch breaks, never to return again. Ever. Some doctors and nurses manage the pan positive review of systems patient by ignoring them. That's right. Some patients just need to be ignored. It's sort of like the Pavlov dogs. If you keep responding to their every complaint, they'll just find something else to complain about. If you ignore them, they will just give up the fight.
Some doctors may spend hours of their own personal time doing extra credit research on Up-To-Date and Google looking for that rare syndrome to explain why that sharp stabbing abdominal pain is relieved only by a double order of KFC extra crispy boneless chicken bites and IV but not oral Dilaudid. I've seen these providers. They are too compassionate for their own good. They want dearly to make all 14 of those pan positive review of systems complaints to go away and they can't get any sleep until that day happens, or until the patient gives up and leaves AMA. These doctors and nurses are being stricken with a nation wide outbreak of pan positive chest pain syndrome. The stress of too many unexplained symptoms is killing our medical providers.
Last but not least, I've seen doctors and nurses who go into head-to-head combat with these patients. They question every little detail the patient gives and they demand accountability for every complaint with an answer that makes physiological sense. They refuse to accept those 14 ridiculous complaints at face value. In the process, these doctors and nurses usually get the patient agitated enough to where they themselves become complaint number 15 on the pan positive ROS and as a bonus, they can now list ROS not obtainable due to patient's aggressive and agitated state of mind. Now they can get full credit for the highest level of care from the Medicare National Bank and move on to the next patient. Huh. These doctors may be on to something. This coding someecard helps to explain.
If that form contains at least 10 organs or systems or if your physician touches at least ten systems in their series of questions, that is considered a complete review of systems and that level of documentation supports the highest level of E/M service your physician can bill for that visit. In other words, obtaining a review of systems is a mandatory component of documentation for most office or hospital face-to-face visits and having that form filled out or subjecting you to that series of questions is a required component to bill at highest level of documentation under Medicare rules.
There are two extreme spectrums in the ROS documentation process. At one end, some patients are unable to provide a ROS because of their underlying acute and or chronic medical conditions. Patients with dementia or delirium are often unable to provide input on their ROS. Some Medicare carriers allow physicians to document ROS not obtainable and receive credit for the highest level of ROS service, as long as documentation supports the reasoning and reasonable attempts are made to document available collateral information.
At the other end of the spectrum is the patient with the pan positive review of systems. This is the patient that answers yes to all ROS questions no matter what the question is. These patients can be painfully difficult to complete the history and physical process. Sometimes I will throw in an impossible symptom I make up that I know to be physiologically impossible just to see if the answer to my question is yes or no.
Pan positive ROS patients can be difficult to manage. They often have comorbid psychiatric conditions and or personality disorders that can make communicating like adults nearly impossible. They can be rude, demanding and manipulative. They can lead to great work place stress for the doctors and nurses taking care of their every catered need.
I have found doctors and nurses all have their own coping mechanisms for handling the pan positive ROS patient. Some doctors and nurses feel pity. Some feel numb. Some go on extra long lunch breaks, never to return again. Ever. Some doctors and nurses manage the pan positive review of systems patient by ignoring them. That's right. Some patients just need to be ignored. It's sort of like the Pavlov dogs. If you keep responding to their every complaint, they'll just find something else to complain about. If you ignore them, they will just give up the fight.
Some doctors may spend hours of their own personal time doing extra credit research on Up-To-Date and Google looking for that rare syndrome to explain why that sharp stabbing abdominal pain is relieved only by a double order of KFC extra crispy boneless chicken bites and IV but not oral Dilaudid. I've seen these providers. They are too compassionate for their own good. They want dearly to make all 14 of those pan positive review of systems complaints to go away and they can't get any sleep until that day happens, or until the patient gives up and leaves AMA. These doctors and nurses are being stricken with a nation wide outbreak of pan positive chest pain syndrome. The stress of too many unexplained symptoms is killing our medical providers.
Last but not least, I've seen doctors and nurses who go into head-to-head combat with these patients. They question every little detail the patient gives and they demand accountability for every complaint with an answer that makes physiological sense. They refuse to accept those 14 ridiculous complaints at face value. In the process, these doctors and nurses usually get the patient agitated enough to where they themselves become complaint number 15 on the pan positive ROS and as a bonus, they can now list ROS not obtainable due to patient's aggressive and agitated state of mind. Now they can get full credit for the highest level of care from the Medicare National Bank and move on to the next patient. Huh. These doctors may be on to something. This coding someecard helps to explain.
