General Surgery Coding Alert

Question: For a level 4 or 5 new patient E/M, I've heard mixed reports about what constitutes a complete review of systems (ROS). Does a complete ROS require that the surgeon review at least 10 systems, or must the review include all 14?California SubscriberAnswer: The review should include all 14 systems to achieve a complete ROS. A complete ROS can support a level four or five new patient E/M or consultation (99204-99205, Office or other outpatient visit..., or 99241-99245, Office consultation ...) or a level five established patient visit (99215, Office or other outpatient visit ...).Your confusion about 10 or more systems is understandable. CMS guidelines state that a complete ROS "inquires about the system(s) directly related to the problem(s) identified in the history of present illness (HPI) plus all additional ... organ systems."Documentation varies: CMS gives you various ways you can document a complete ROS, as follows:Individually document all [...]