Beware: Multi-system reviews must exceed system elements in HPI. Don't open your practice to lost revenue or audit concerns by choosing the wrong review of systems (ROS) level and miscoding E/M services. Use these tallyingmade- easy tips. Use System List When Compiling ROS An ROS is an "inventory of body systems or symptoms about which the provider asks the patient," to help the physician in establishing a diagnosis. This information is also used to assist in coding, explains Providers perform an ROS to identify potential problems that were not elicited in the history of present illness (HPI) portion of the exam. Boiled down: CPT breaks the body into these systems: • constitutional symptoms • eyes • ears, nose, mouth, and throat • cardiovascular • respiratory • gastrointestinal • genitourinary • musculoskeletal • integumentary (skin and/or breasts) • neurologic • psychiatric • endocrine • hematologic/lymphatic • allergic/immunologic. In short, "the ROS assists physicians as they narrow down diagnostic possibilities, and it focuses on the patient's signs and symptoms," relays Example: By performing a thorough ROS, the pulmonologist can get a better idea of what the cause is for the patient's shortness of breath. Follow-Up Visits Are Often Problem-Pertinent Be sure to keep count of the ROS total for each E/M encounter, as there are three levels of ROS. The first level of ROS is problem-pertinent. The pulmonologist performs this ROS when he reviews only the system related to the patient's problem. Thus, if the patient has shortness of breath, the pulmonologist may ask if the patient experiences any coughing or painful respiration. Depending on the other encounter specifics, a problem-pertinent ROS can support up to a level-two new-patient E/M: • 99202 -- Or a level-three established-patient E/M: • 99213 -- According to Gilhooly, many follow-up visits for patients with stable, chronic conditions that have plans of care in place utilize a problem-pertinent ROS. Example: Extend Your E/M Options With This ROS Level When the physician reviews between two and nine systems during an E/M, he has performed an extended ROS, Bauer says. These reviews may result in detailed histories and, depending on the remaining encounter specifics, can support up to a level-three new-patient E/M: • 99203 -- Or a level-four established-patient E/M: • 99214 -- Remember: Example: • "Do you have or have you experienced difficulty with breathing, wheezing, chronic cough, or dyspnea on exertion?" • "Do you have any trouble with chest pains radiating to your neck or arms when exercising or walking? Any problems with irregular heart beats or pain in your legs when walking (claudication)?" • "Do you have any trouble with stomach pains after eating, heartburn, or change in bowel habits?" In this example, the pulmonologist reviewed four systems (cardiovascular, respiratory, musculoskeletal, gastrointestinal), so this is an extended ROS. Don't forget to ask the right questions to achieve a thorough ROS. The pulmonologist should ask pointed questions when conducting the ROS, recommends Gilhooly. Bad ROS question: This will not qualify for a complete ROS. However, if the doctor went on to ask direct questions about eight other systems (for a total of ten systems), the encounter qualifies for complete ROS -- even if the findings for those systems were negative.