Ob-Gyn Coding Alert

Question: What is meant by the review of systems (ROS) levels?

California Subscriber Answer: Four ROS levels exist that contribute to the level of history selected for an E/M service. ROS progresses from -nonavailable- or -nonapplicable- to -problem-pertinent- to -extended- and -complete.-
 In a problem-pertinent ROS, the ob-gyn asks questions about the system directly related to the problem identified in the history of present illness (HPI).
 
When the physician asks about a limited number of additional systems, he meets the criteria for an extended ROS. Important: Documentation must include positive responses and pertinent negatives for two to nine systems, according to both the 1995 and 1997 Documentation Guidelines for E/M Services.
 
A complete ROS requires inquiring about all organ systems. The physician must review at least 10 organ systems and individually document those systems with positive responses and pertinent negatives. Tip: For the remaining systems, he can use a notation to indicate that all other systems are negative. Without such a notation, he must individually document at least 10 systems in order for the documentation to support a complete ROS.