Internal Medicine Coding Alert

Question: I have a question about the review of systems (ROS) portion of E/M services. What is the difference between problem pertinent, extended and complete ROS?


Kentucky Subscriber

Answer: You’ll need to know the difference between the three ROS levels because ROS is a vital component to determining your E/M code level.

According to the 1995 Documentation Guidelines for Evaluation and Management Services:

Problem pertinent: A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the history of present illness (HPI). The healthcare provider should document the patient’s positive responses and pertinent negatives for the system related to the problem.

Extended: An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems. The provider should document the patient’s positive responses and pertinent negatives for two to nine systems.

Complete: A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI, plus all additional body systems. According to the Documentation Guidelines: “At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible.” In the absence of such a notation, at least 10 systems must be individually documented.