Pulmonology 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 and documents during the patient encounter. Medicare identifies the following systems for documentation purposes:

• 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.

Check out these ROS level definitions, from the 1995 Documentation Guidelines for E/M Services:

A problem-pertinent ROS inquires about the system [meaning one] directly related to the problem(s) identified in the history of present illness (HPI). Documentation should include the patient's positive responses and pertinent negatives for the system related to the problem.

A problem-pertinent ROS can support up to a level-two new patient E/M (99202, Office or other outpatient visit for the E/M of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision-making ...) or a level-three established patient E/M (99213, Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity).

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems. The pulmonologist should document the patient's positive responses and pertinent negatives for two to nine systems for this level.

An extended ROS can support up to a level-three new patient E/M (99203, ... a detailed history; a detailed examination; medical decision-making of low complexity) or a level-four established patient E/M (99214, ... a detailed history; a detailed examination; medical decision-making of moderate complexity).

A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems. For this level, the pulmonologist must review at least 10 organ systems, and he must individually document those systems with positive or pertinent negative responses.

"For the remaining systems, a notation indicating all other systems are negative is permissible," according to CMS' documentation guidelines. (Note: A few local Medicare contractors prohibit use of this statement, requiring the physician to then list 10 systems with a corresponding notation.)