Ophthalmology and Optometry Coding Alert

Question: What is the best way to document review of systems (ROS)? We know ancillary staff can record the ROS, but we aren't sure what the documentation has to include.

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Answer: This can be one of the trickiest issues for coders for three reasons. First, some coders confuse past medical history with ROS. For example, if the provider documents, "No known drug allergies," this is past medical history and not ROS. To count as ROS, the provider would need to document something like, "no blurred vision," which would count as a review of the Eyes system.

A second point of confusion for coders can arise over whether negatives should be included in the review. Providers should document both positive and negative findings for any pertinent system. So, a review of the respiratory system for a patient complaining of eye pain could include notes about negatives, such as "No complaints of blurred vision, no watering," as well as positives such as "Eye burns approximately twice a week, particularly after driving."

Coders should also note that an extended or complete ROS can include reviews of systems that are not directly related to the problems identified in the history of present illness (HPI). In the above example of the patient complaining of eye pain, you could count a review of the ears, nose, mouth, and throat if your provider documented that the patient had "no complaints of headache, dry mouth, or problems with the nose or ears."

In other words, something needs to be documented in order to count toward the E/M level of service. Simply put, it is important to have evidence that the review took place. A simple notation of "negative" or "normal" can suffice for systems that aren't the key focus of the presenting problem but are pertinent to inquire about. Along with a more detailed system review of the key symptomatic system, a generic statement such as "a 10-part systems review was otherwise negative." is acceptable to most payers; however, the comment "ROS otherwise negative" is insufficient.