Pulmonology Coding Alert

Question: What is the right way to document review of systems (ROS)? We known ancillary staff can record the ROS but we aren't sure what the documentation has to include.

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Answer: This can be one of the trickiest issues for coders for three reasons. First, some coders confuse past medical history with ROS. For example, if the provider documents, "No known drug allergies," this is past medical history and not ROS. To count as ROS, the provider would need to document something like, "no wheezing," which would count as a review of the respiratory system.

A second point of confusion for coders can arise over whether negatives should be included in the review. Providers should document both positive and negative findings for any pertinent system. So, a review of the respiratory system for a patient complaining of chest pains could include notes about negatives, such as "No complaints of wheezing, no blood in sputum, no persistent cough," as well as positives such as "Burning chest pain, approximately twice a month, particularly when exercising."

Coders should also note that an extended or complete ROS can include reviews of systems that are not directly related to the problems identified in the history of present illness (HPI). In the above example of the patient complaining of chest pains, you could count a review of the eyes and ears, nose, mouth, and throat if your provider documented that the patient had "no complaints of change in vision, or problems with the nose or ears."

In other words, something needs to be documented in order to count toward the E/M level of service. Simply put, it is important to have evidence that the review took place.

If the review is performed by the ancillary staff, and documented in the note with a legible identifier, the physician can include this information in his/her documentation and reference this information, "ROS as noted above."