Urology Coding Alert

Question: Does the urologist need to specifically document all 14 systems for the review of systems (ROS) portion of a consult or can he simply state in the documentation that he reviewed 14 systems along with the details of any pertinent findings?

Alabama Subscriber

Answer: The requirements for the ROS depend on the level of consultation you are reporting. The lower the consultation level reported, the fewer documentation requirements for ROS.

Consultation code 99241 requires a problem-focused history only, which means the urologist doesn't need to document an ROS. CPT code 99242 requires an expanded problem-focused history, which means only a problem-pertinent ROS (urinary system) needs to be present in the documentation. And 99243 requires clear documentation of two to nine systems to meet the detailed history requirement. As for the highest consultation levels, 99244 and 99245, the physician must document a "complete" ROS to report these codes.

According to AMA and CMS guidelines, a "complete" ROS consists of documented review of only 10 organ systems, not 14. "Those systems with positive or pertinent negative responses must be individually documented for the remaining systems, a notation indicating all other systems are negative is permissible," according to the July 1997 CPT Assistant. "In the absence of such a notation, at least 10 systems must be individually documented" and can be recorded by the patient or ancillary staff, such as a nurse, medical technician, or medical student, and reviewed individually.

Consequently, you do not need to enumerate the 10 systems individually. Document the positive and pertinent negative ROS responses and then indicate that the remaining "up to 10 systems" are negative. Commenting on whether the patient has had fever or chills (constitutional review) and the patient's bowel habits (gastrointestinal system review) account for documentation of two systems, which meets the requirement for a 99243 consultation code.

These ROS guidelines apply to both outpatient consultation codes (99241-99245) and inpatient consultation codes (99251-99255). Remember, ROS is only one element of the history component of E/M documentation.