One of the benefits of admitting a 90 year old demented patient to the hospital is documenting unobtainable review of systems due to baseline dementia. This is allowed under the published CMS evaluation and management (E/M) rules. This documentation will qualify the ROS component for the highest level of care associated with that patient's evaluation.
It's actually quite silly; that whole idea of paying a physician based on how many predefined questions they ask , not whether asking those questions is medically necessary or not. In theory, asking all these silly questions every time will always be medically necessary because you don't know if the questions have relevance until after the questions have been asked. In practice, it's a waste of time and physicians ask questions based on their style of interview as well as back and forth give and take communication between patient and doctor.
A list of questions called the review of systems is worthless, except in the eyes of payers who define effort, and therefor payment, based on ROS documentation. As a hospitalist in the field for almost a decade, I can tell you that the complete review of systems will always be medically necessary, but often irrelevant. The same goes for the complete physical exam. Always medically necessary, often irrelevant. But these are the rules we have been given. That's why I'm a huge fan of bundled care. Pay me to care for patients the way I think is best, not the way payers thinks is worth it and I could double or triple the number of patients I see in a day without any lose of quality concerns.
Taking histories and doing physicals is what all physicians have been trained to do. And thoroughness defines our practice as physicians. We ask questions in search of answers. We examine in search of a diagnosis. But telling us what's important and what we need to document in order to get paid isn't. If that isn't the most inefficient distraction to the delivery of efficient, high quality medical care, then I don't know what is.
A review of systems is really not all that helpful in the clinical course of how physicians do their patient evaluations. That might come as a shocker to new medical students brainwashed by their attendings with their three hour, six page evaluations with no plan, on their first day of internal medicine, but it's readily apparent by the time you're trying to decide on your 4th year rotations to take in medical school. It's time for the review of systems to die a quick death. I am not a fan by any means.
The review of systems process is nothing more than a generation of mostly worthless information that no one reads. It has limited bearing in how we work through our differential diagnosis. I presume the whole ROS process was created as a way to implement defined payment structures for E/M notes. Documenting the ROS is really a documentation headache of magnificent proportions.
Which is why I'm also glad CMS has allowed us the right to document something along the lines of "except as previously dictated, all other review of systems were reviewed and are negative without further pertinent positives or negatives" and that statement constitutes the requirements in place of a two page list of ROS dictated questions, at least if you aren't being forced to use the obnoxious Trailblazer criteria that some Medicare carriers have elected to adopt. Who do these people think they are? It's just one obstruction after another to get paid for work provided.
I make that statement dozens of times a month because that's what I must document in order to get paid for the work provided. We do it because that's how we get paid. It's medically necessary. It will always be medically necessary. But, hindsight usually tells us it has no relevance to patient care or outcomes. The next time you find a cardiologist asking you if you have any history of pain with urination, you can be assured he or she has to ask you if he wants to get paid and not be accused of fraud, not that he cares or that it matters one bit to the medical decision making process he's about to implement.
Now that I've established the complete idiocy of our review of systems process and how obstructive it is to our normal work flow in the course of daily patient care, I'd like to present to you how these online symptom checkers are taking the ROS to new unbelievable heights. Instead of accepting the process as nothing more than a miserable attempt to quantify effort, they have taken the ROS to the next level of absurdity. Here's an example of how WebMD's online symptom checker has shown, in true form, how absurd the ROS has become.
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I suppose it's only a matter of time before CMS starts accusing physicians of fraud for not documenting a patient's trembling associated with cannibalism in Papua New Guinea in their complete review of systems. Because we all know how warped these Medicare fraud statistics really are.
