Primary Care Coding Alert

Question: There are three review of systems (ROS) levels: problem-pertinent, extended and complete. What are the differences among these three levels? Nebraska Subscriber Answer: Each ROS level is defined by the number of systems your physician checks during the patient encounter. Medicare defines these systems for documentation purposes:
- constitutional symptoms (e.g., fever, weigh loss)
- eyes
- ears, nose, mouth and throat
- cardiovascular
- respiratory
- gastrointestinal
- genitourinary
- musculoskeletal
- integumentary (skin and/or breasts)
- neurologic
- psychiatric
- endocrine
- hematologic/lymphatic
- allergic/immunologic. Problem-pertinent: When the physician performs a problem-pertinent ROS, he reviews one system for the patient during the E/M. Depending on the encounter specifics, this ROS type could support up to a level-two new patient E/M (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 a level-three established patient service (99213, - an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity). Extended: For an extended ROS, the FP must show that he checked from two to nine systems. An extended ROS can support up to a level-three new patient service (99203, - a detailed history; a detailed examination; and medical decision-making of low complexity) or level-four established patient services (99214, - a detailed history; a detailed examination; medical decision-making of moderate complexity). Complete: The FP must review at least 10 organ systems for a complete ROS, and he must individually document each system with pertinent positive or negative responses. The Medicare documentation guidelines also allow a notation indicating "all other systems are negative" to qualify for a complete ROS, but this is a documentation exemption, not a performance exemption. The physician must still check those "negative" systems.