Optometry Coding & Billing Alert

Question: What is the difference between the -review of systems- (ROS) levels for the E/M codes?

South Carolina Subscriber

Answer: Four ROS levels exist that contribute to the level of history selected for an E/M service. ROS progresses from -nonavailable- to -problem-pertinent- to -extended- and -complete.-
 
CPT has identified 14 elements of a system review: constitutional systems (e.g., fever, weight loss); eyes; ears, nose, mouth and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (i.e., skin or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.
 
In a problem-pertinent ROS, the optometrist asks questions about the system directly related to the problem identified in the history of present illness (HPI).
 
ROS for -eyes- includes the date of the patient's last eye exam; when the patient was last checked for glaucoma (if over 50); current eye infections or injury; eyeglasses; contact lenses; current eye discharge or excessive tearing; pain; and visual disturbances or spots/floaters. Some of these may be part of the presenting problem.
 
However, if the optometrist reviews the eyes beyond the presenting problem (e.g., -patient has worn contact lenses for the last five years-), the additional information may be counted in the ROS.
 
When the optometrist 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 the 1995 Documentation Guidelines for E/M Services.
 
A complete ROS requires inquiring about the system(s) directly related to the problem(s), plus all other body systems. The optometrist 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.
 
Many optometrists have their patients fill out information about the review of systems as part of the pre-visit paperwork, which allows the optometrist to review the document in the patient's presence.