Pulmonology Coding Alert

Question: Who can record the review of systems, and how should we document it?

Codify Subscriber

Answer: The review of systems (ROS) can be recorded by the patient or any clinical staff within the office; however, the provider’s review of information obtained in the ROS must be evident within the record in order for the coder to use it toward the justification of the code.

As far as the documentation requirements for ROS, it is important to document both positive and negative findings for any pertinent system. So, a review of the cardiovascular system for a patient complaining of trouble breathing could include notes about negatives, such as “No complaints of heart palpitations, leg swelling, or chest tightness,” as well as positives such as “Cough that produces sputum about twice a week, fatigue after walking long distances.”

But it is important that ROS documentation sticks with elements related to a system and not to the patient’s past medical history. For example, if the provider documents, “No known drug allergies,” this is past medical history and not ROS.

The 2019 Medicare Physician Fee Schedule specifies that “for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.”

Reference: https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year.