Dermatology Coding Alert

Question: When a dermatologist lists an organ system and documents past medical/surgical history instead of current signs or symptoms, can I use this as review of systems (ROS)?

Illinois Subscriber

Answer: Ask your dermatologist if the past medical/surgical history constitutes an ROS. Show him the CPT guidelines and have him clarify what he believes to be a review of systems. The CPT guidelines indicate that the past medical history indicates a patient's past experiences with an illness or injury. But, in contrast, a review of systems (ROS) is an inventory of questions based on the history of the patient's presenting illness.

The answers to the ROS questions determine the type and extent of the exam the physician conducts. Answering the "inventory" questions can provide the physician with the past medical history. Encourage your physician to indicate the systems reviewed and record the positive and pertinent negatives for each system addressed.