# Review of Systems - records and labs count



## reinelt (May 23, 2016)

Does looking at a CT result for a head CT count as a ROS?  Also, does looking at data points like old records and labs count towards the E/M calculation?


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## lisigirl (May 23, 2016)

no, think of a review of systems as a review of "symptoms." These are subjective statements from the patient (e.g., no chest pain, no SOB, no fever, etc). The provider is credited one point for ordering or reviewing a CT scan result under the data section of MDM. Or, if the physician personally reviews the scan (and not just the result written by the radiologist), he/she can get 2 pts.

Do you have an E/M abstraction worksheet?

Lisi
eharkler@nm.org


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## reinelt (May 24, 2016)

Review of Systems is the physical exam.  But I will let the doctor know about the 1 and 2 points.  Thank you for your help.


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## LuckyLily (May 24, 2016)

The "review of systems" is not the "physical exam". If you are coding this way then this is a huge error and everything coded has been incorrect.


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## cerullhon (May 25, 2016)

*ROS documentation combined with Physical Exam*

This is for In Patient Hospitalist coding.  Can the ROS documentation be combined in with the Physical Exam?  My Provider does not have a "ROS" heading, but states the ROS is combined in the Physical Exam.


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## JEYCPC (May 25, 2016)

cerullhon said:


> This is for In Patient Hospitalist coding.  Can the ROS documentation be combined in with the Physical Exam?  My Provider does not have a "ROS" heading, but states the ROS is combined in the Physical Exam.



I don't believe so.  Maybe he means for subsequent visits?


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## cerullhon (May 25, 2016)

No, these are new In Patient Hospital Visits.  His documentation is all over the place and sometimes he doesn't list the ROS.  Due to the 3/3 rule, we can't credit him for a New Visit and have to downcode to subsequent.  However, he states the ROS is within the body of the Physicial Exam (it isn't_).  Even if it was,  "double dipping" is not allowed in any of the E/M components.  We have even provided documentation from CPT book, Wikipedia and and info from a E/M seminar we attended given the definition of "ROS".

I'm at a loss of what else to do.


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## mhstrauss (May 25, 2016)

cerullhon said:


> No, these are new In Patient Hospital Visits.  His documentation is all over the place and sometimes he doesn't list the ROS.  Due to the 3/3 rule, we can't credit him for a New Visit and have to downcode to subsequent.  However, he states the ROS is within the body of the Physicial Exam (it isn't_).  Even if it was,  "double dipping" is not allowed in any of the E/M components.  We have even provided documentation from CPT book, Wikipedia and and info from a E/M seminar we attended given the definition of "ROS".
> 
> I'm at a loss of what else to do.



Here's the best explanation I could find on the difference between ROS and PE...I know you said you've given him info previously, but possibly try once more?

http://www.medicalcoding123.com/2012/09/ros-vs-physical-exam.html

The only other point I can think of, is that some MAC's/payers will allow elements from the HPI to be used in the ROS. You'd have to check with your region's MAC for clarification though. Here's Novitas, as an example (see #15):

http://www.novitas-solutions.com/we...f.ctrl-state=g6dbl44pl_84&contentId=00005056#!


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## cerullhon (May 26, 2016)

Thank you for the link....beautifully described!


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