Urology Coding Alert

Question: Can we count a “complete” ROS when the surgeon includes a statement such as “A 10-point ROS was negative” in the exam notes?

North Dakota Subscriber

Answer: No, this does not merit a complete review of systems (ROS). Reporting as “negative” any number of systems fewer than 14 does not satisfy the abbreviated notation requirement for ROS when you’re determining the appropriate E/M level for the encounter.

Remember:  A complete ROS means that the physician reviewed all 14 systems. But according to the 1995 and 1997 E/M Documentation Guidelines, if the physician reviews and individually documents 10-plus systems with positive or pertinent negative responses, you are allowed to use a statement such as “all other systems are negative” to claim a complete ROS. Such a combination (10 documented, all other negative), clearly indicates a complete ROS.

Here’s the confusion: Many coders confuse these two facts and conclude that a statement such as the one you cited (a 10-point ROS was negative) fulfills the “complete ROS” requirement, but it does not. Such a statement does not identify which 10 systems the physician reviewed. Using words like “noncontributory” also confuses the issue, because it suggests there were positive answers that weren’t recorded. Explain this to your providers and remind them that the more specific they are in their documentation, the more accurately you can code for their services.

Do this: Ensure that the surgeon documents all positive ROS and any pertinent negative ROS. If the documentation includes at least 10 systems and the surgeon also states that the remaining systems are negative, you may claim a complete ROS.