Anesthesia Coding Alert
Know Levels to Take Your ROS Up a Notch
Kentucky Subscriber
Answer: Four ROS levels contribute to the level of history selected for an E/M service. ROS progresses from "nonavailable" to "problem-pertinent" to "extended" and "complete."
In a problem-pertinent ROS, your physician asks questions about the system directly related to the problem the patient identified in the history of present illness (HPI).
When the physician asks about a limited number of additional systems, he meets the criteria for an extended ROS. Important: Documentation must include positive responses and pertinent negatives for two to nine systems, according to CMS' 1995 Documentation Guidelines for E/M Services.
A complete ROS requires inquiring about all body systems. The physician must review at least 10 organ systems and individually document those systems with positive responses and pertinent negatives.
Tip: For the remaining systems, your physician can use a notation to indicate that all other systems are negative. Without such a notation, he must individually document at least 10 systems.
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