Oncology & Hematology Coding Alert

Now that you-ve given the ROS question your best shot, see what our expert has to say.

Answer: As long as the physician signs the nurse's notes and documents that he reviewed them, you can meet the requirements for ROS and PFSH with information from the nurse's notes, says Susan Vogelberger, CPC, CPC-H, business office coordinator at Beeghly Medical Park in Ohio.

-I tell the physician to sign and date the nurse's note, as well as to refer to it in his own notes,- she says.

Tip: Any individual acting in an incident-to capacity can perform the ROS and PFSH--the individual doesn't have to be a nurse.

You-ll use ROS and PFSH, along with the patient's physician-documented HPI, to decide the information level the physician gathered about the patient's history.

The ROS is basically an inventory of the body so the physician knows where to direct the physical examination. The inventory may include evaluations of any of the following systems or parts: allergic/immunologic, cardiovascular, constitutional symptoms, ears/nose/mouth/throat, endocrine, eye, gastrointestinal, genitourinary, hematologic/lymph, integumentary, musculoskeletal, neurological, psychiatric, and respiratory.

Learn the ROS Levels

For a problem-pertinent ROS, the physician needs to review a single system or part and will usually follow the guidelines of the E/M codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making) or 99203 (... a detailed history, a detailed examination, and medical decision-making of low complexity).

If the physician reviews two to nine systems, you should consider the ROS -extended,- which means it usually translates to 99203.

If he reviews at least 10 systems, the ROS is -complete,- which may earn a 99204 (... a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity) or 99205 (... a comprehensive history, a comprehensive examination, and medical decision-making of high complexity).

Learn the PFSH Levels

A -pertinent- PFSH consists of a comment in any one of the histories--information about a patient's past health history, family history, or social history--and helps you on your way to a 99203.

For a -complete- PFSH, the doctor must have information that involves all three of the histories. The complete PFSH translates into 99204 or 99205, depending on the level of medical decision-making.