ED Coding and Reimbursement Alert

Question: Can a doctor use diseases as a review of systems (ROS)? For example: no renal disease, coronary artery disease, etc. Does this type of inquiry fulfill ROS requirements? If a system is listed as positive, can we use that to count as a requirement for medical history? If we have met our requirements for history and present illness (HPI) and have extra associated signs and symptoms, can these be used for ROS?

New York Subscriber

Answer: Yes, stating no renal disease, coronary disease, etc., can be used in the ROS. Had these diseases been positive, they would have counted as part of the past medical history. The elements of each component of the history should stand alone and, according to payer interpretation, in most cases should not be used more than once. However, there is now no CPT clarification that elements may not be used more than once. Common sense would dictate, however, that a condition positive for the HPI would also qualify as positive in the medical history and the ROS. Payer guidelines will determine how.

For example, if a patient presents with chest pain, shortness of breath and nausea, the chest pain would be the presenting problem, the shortness of breath would be the associated sign or symptom, and the nausea could be used as the ROS. You cannot use the same element in the same area twice. For example, for HPI, if you have a patient who presents with chest pain for three hours, you couldnt use the three hours for both timing and duration.