General Surgery Coding Alert

Question: Our surgeon evaluated a patient for surgery for abdominal endometriosis following a complete hysterectomy for endometriosis. Can we still count the genitourinary system toward the ROS to determine the E/M level even though the reproductive organs have been removed?

Texas Subscriber

Answer: Yes, you can count the genitourinary system toward the review of systems (ROS) for your E/M level. ROS is part of the history for an E/M service that the physician uses to understand what has gone on with the patient in the past. Of course a review of the genitourinary system would be an important part of evaluating a patient post-hysterectomy for recurrent endometriosis.

A system is a system, not an organ. "You have other organs within the system that might be very important toward the examination and the decision-making of the physician," says Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med Group in Pittsburgh. "In fact, those systems might be more important because of the lack of one of the components."

For instance: In this case, the surgeon might want to rule out kidney involvement or any prolapse or complications affecting the bladder, ureters, or urethra -- all of which deal with the genitourinary system, even though the patient has had a complete hysterectomy.

Refresher: There are 14 systems that count toward the ROS, and the physician addresses a system by asking the patient questions regarding signs and symptoms involving one or more systems. Your surgeon should document which systems the review addresses.