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Primary Care Coding Alert

READER QUESTIONS:

Take Your ROS up a Notch

Published on Fri Jun 23, 2006

Question: What is the difference between 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- to -problem-pertinent- to -extended- and -complete.-

In a problem-pertinent ROS, the family physician 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 the 1995 Documentation Guidelines for E/M Services.

A complete ROS requires inquiring about all body 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.
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