General Surgery Coding Alert

Document positive or pertinent negative responses.

If you don't get the correct count of your surgeon's review of systems (ROS) for the "history" portion of a patient visit, you'll never get the E/M code right.

Keep ROS from becoming an issue in your surgical practice by reviewing these expert FAQs on the subject.

Define ROS for Starters

Question 1: What Is ROS?

Answer 1: ROS is part of the History portion of the note that describes current symptoms the patient is experiencing that may be related to chronic conditions the patient has.

The "systems" referenced in ROS are:

• Constitutional symptoms (fever, weight loss, etc.)
• Eyes
• Ears, nose, mouth, throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/lymphatic
• Allergic/immunologic

To conduct ROS, the physician asks a series of questions related to the patient's signs/symptoms. Providers use ROS data to zero in on the problem by helping to clarify a differential diagnosis and identifying any needed testing.

ROS will also help the accumulate "baseline data on other systems that might be affected by any possible management options," explains Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb.

Remember: To bulwark your ROS coding, be sure that the systems the physician reviews relate to the systems listed as problems in the history of present illness (HPI), says Jan Blanchard, CPC, CPMA, consultant at Vermont-based PCC. If there's no link between ROS and HPI, you might have to review your ROS choice.

Know the ROS Choices

Question 2: What Are the Different ROS Levels?

Answer 2: There are three different levels of ROS, says Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Ill.:

1. Problem-pertinent: For a problem-pertinent ROS, the physician must review a single system. So, if the provider treats a patient for a headache, and notes indicate that he reviewed the neurological system, it's a problem-pertinent ROS.

2. Extended: The physician must review between two and nine systems for extended ROS. So, if the provider treats a patient for a headache, blurred vision, weight loss, and panic attacks, he's reviewed four systems, and it's an extended ROS, as follows:

• Neurological
• Eyes
• Constitutional symptoms
• Psychiatric.

3. Complete: If the physician reviews at least 10 systems, you might be able to mark complete ROS. According to the 1995 and 1997 E/M Documentation Guidelines, you must review and individually document all 10-plus systems with positive or pertinent negative responses for complete ROS. For the remaining systems, a notation indicating "all other systems are negative" is allowable. However, simply stating any number of ROS less than 14 »»»» (such as, "a 10-point ROS was negative") does not satisfy the abbreviated notation requirement.

Understand ROS's Place in E/M Code System

Question 3: How Does ROS Affect Coding?

Answer 3: You might not need ROS evidence if you are coding for an established patient evaluation and management (E/M) service (99211-99215), because these codes require only two of the three key "HEM" components (history, exam, medical decision making). ROS is vital, however, on new patient E/Ms 99201-99205, which require all three components. Without ROS, you cannot adequately perform the history portion of the exam, so be ready to spot ROS on all new patient E/Ms.

ROS might also affect your E/M code level. Depending on other encounter specifics, a problem-pertinent ROS can support up to a 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ...) E/M for new patients, or 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) for established patients.

An extended ROS can support up to a 99203 (... a detailed history; a detailed examination; medical decision making of low complexity ...) E/M for new patients, or 99214 (... a detailed history; a detailed examination; medical decision making of moderate complexity...) for established patients.

Further, depending on the other specifics of the encounter, a complete ROS can support up to a 99205 (... a comprehensive history; a comprehensive examination; medical decision making of high complexity ...) E/M for new patients, or a 99215 (... a comprehensive history; a comprehensive examination; medical decision making of high complexity ...) for established patients.

Warning: You should not assume that you can automatically code all complete ROS encounters with high-level E/M codes. Other elements of the encounter - the remaining history elements, plus examination and medical decision making - must also satisfy E/M requirements to justify your code choice.