Gastroenterology Coding Alert

Do you know what it takes for ROS to be -complete-?

Review this basic information about review of systems (ROS), and you-ll be capturing your ROS levels correctly every time.

What it is: The ROS is basically an inventory of the body so the physician knows where to direct the physical examination. The inventory may include evaluations of any of the following systems or parts: allergic/immunologic, cardiovascular, constitutional symptoms, ears/nose/mouth/throat, endocrine, eye, gastrointestinal, genitourinary, hematologic/lymph, integumentary, musculoskeletal, neurological, psychiatric, and respiratory. The ROS alone does not determine the service level, but if your physician does not document any ROS, you cannot report higher levels of service.

If your physician has only done a problem-pertinent ROS, which represents the review of only one system, you-ll only be able to report 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components:  a problem-focused history, a problem-focused examination, and straightforward medical decision-making) or 99202 (... an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision-making). The determining factor will be the level of exam, not the level of medical decision-making.

If your physician reviews two to nine systems, you should consider the ROS -extended,- which means your coding can translate to 99203 if he documents an extended HPI, mentions one element from past, family or social history, does a detailed examination, and performs low-complexity medical decision-making.

If he reviews at least 10 systems, the ROS is -complete,- which may earn a 99204 (... a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity) or 99205 (... a comprehensive history, a comprehensive examination, and medical decision-making of high complexity) if your physician documents all other required elements.

A -pertinent- PFSH consists of a comment in any one of the histories ��" information about a patient's past health, family or social history ��" and helps you on your way to a 99203. For a -complete- PFSH, the doctor must have information that involves all three of the histories. The complete PFSH translates into 99204 or 99205