ED Coding and Reimbursement Alert

Question: There are three review of systems (ROS) levels: problem-pertinent, extended and complete. What are the differences among these three levels? Nebraska Subscriber Answer: Each ROS level is defined by the number of systems your physician checks during the patient encounter. Medicare defines these systems for documentation purposes: - constitutional symptoms - eyes - ears, nose, mouth and throat - cardiovascular - respiratory - gastrointestinal - genitourinary - musculoskeletal - integumentary (skin and/or breasts) - neurologic - psychiatric - endocrine - hematologic/lymphatic - allergic/immunologic. Problem-pertinent: When the physician performs a problem-pertinent ROS, he reviewed one system for the patient during the E/M. Depending on the encounter specifics, this ROS type could support up to a level-three E/M (99283, Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of moderate complexity). Extended: For an extended ROS, the ED physician must show that he checked between two and nine systems. An extended ROS can support up to a level-four service (99284, - a detailed history; a detailed examination; and medical decision-making of moderate complexity). Complete: The ED physician must review at least 10 organ systems for a complete ROS, and he must individually document each system with pertinent positive or negative responses. The Medicare documentation guidelines also allow a notation indicating "all other systems are negative" to qualify for a complete ROS, but this is a documentation exemption for the ED physician, not a performance exemption. Remember, the physician must still check those systems he deems "negative."