Internal Medicine Coding Alert

Question: When an internist lists an organ system and documents past medical/surgical history instead of current signs or symptoms, can I use this as the ROS?


Florida Subscriber

Answer: The CPT guidelines state that the past medical history indicates a patient's previous experiences with an illness or injury. But, in contrast, an ROS is an inventory of questions based on the history of the patient's presenting illness.
 
The answers to the ROS questions determine the type and extent of the exam the internist conducts. Answering the inventory questions can provide the physician with the past medical history. Encourage your internist to indicate the systems reviewed and record the positive and pertinent negatives for each system addressed.

So if your internist does not document information about the patient's current symptoms, but only mentions the patient's past medical history, you should only count the information as part of the tally for past medical history.