Urology Coding Alert

Question: We have some differences in opinion in our office regarding how often we should update the ROS (review of systems) for a patient. We all know that you can use the ROS from a previous visit as long as you reference the original date, but don’t agree on how long you can rely on that particular ROS. We have files on some patients who haven’t had an updated ROS in several years, which I think is questionable. I was taught that you need a new ROS whenever the patient presents with a new problem or when a new anatomic site is being treated. What’s your advice on how often we should update the ROS?

New Jersey Subscriber

Answer: Your question is not unusual and the answer can be tricky because current E/M guidelines don’t specify how often you should update a patient’s ROS. From a medically relevant perspective, however, your training was spot-on: your physician should update the ROS every time he sees a patient and requires a review of some or all of the systems.

Many practices ask patients to complete an ROS form each year. Then, at every visit, the physician updates the information based on the medical necessity of the current encounter. When considering years, it doesn’t matter how far back the ROS goes as long as the physician consistently updates it as appropriate.

Bottom line: Your physician must stay current on a patient’s medical condition. The patient’s condition and your physician’s role within treating that condition dictate how often the ROS should be updated.