EM Coding Alert

Question: Our providers are having trouble understanding what levels of ROS there are. Can you explain?

Texas Subscriber

Answer: Review of systems (ROS) is part of the history component of an E/M service. CPT^® defines it as “[a]n inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced.”

During ROS, the physician might review systems directly related to the problem or problems identified in the HPI portion of the E/M and a number of additional systems.

According to both the 1995 and 1997 CMS documentation rules, there are three different levels of ROS, and you must identify ROS level before choosing a level of history and, subsequently, an E/M code.

When the physician reviews a single system, it is a problem-pertinent ROS. This ROS level can support up to a level-two new patient E/M (99202) or a level-three established patient service (99213).

When the physician reviews two to nine systems, the encounter is an extended ROS. Extended ROS can support up to a level-three new patient service (99203) or level-four established patient service (99214).

Caveat: An extended ROS does not necessarily qualify an encounter for 99203 or 99214; though it does make reporting these codes possible.

For a complete ROS, most insurers accept a review of 10 or more systems. The provider must individually document those systems with positive or pertinent negative responses. For the remaining systems, a notation indicating all other systems are negative is permissible. Absent such a notation, the provider must individually document at least 10 systems.

With a complete ROS, reporting a 99204, 99205, or 99215 is possible — depending on other encounter specifics.