ED Coding and Reimbursement Alert

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

Illinois Subscriber

Answer: In a word, no. Using past medical history terminology to code ROS, for example, skin: no history of melanoma, or genitourinary: no history of hysterectomy, or cardiovascular: no history of myocardial infarction, is incorrect coding because these are not ROS comments.

Differentiate ROS documentation by looking at it as typically current information about systems. For example, the review of skin would be marked negative or no complaints of rash if there is no skin problem at the time of the patients ED visit. Respiratory system ROS documentation would indicate, patient complains of having trouble breathing.