Overlooking ROS Can Result in Downcoding of New Patients and Consultations

By Belinda S. Frisch, CPC

The review of systems (ROS) is an inventory obtained through a series of questions identifying signs or symptoms of illness the patient is experiencing or has experienced. Neglecting to document required ROS elements is one of the top reasons that evaluation and management (E/M) new patient and consultation services are downcoded during an audit.

The systems reviewed are: constitutional (for example, weight loss); eyes; ears, nose, mouth, and throat (ENMT); cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (skin); neurologic; psychiatric; endocrine; hematologic/lymphatic/immunologic; and “all other systems negative.”

An ROS must be evaluated by the physician but can be documented by ancillary staff, a nurse, or the patient on a form. If an ROS is unobtainable from the patient, the record should state why. It is unnecessary to re-document the ROS for subsequent visits  if there is evidence the physician reviewed and updated the original ROS (such as by documenting “no change since ROS dated 1/1/08”). For audit purposes, the original level of ROS will be applied to the subsequent visit if such a notation exists.

CPT® codes for new patients and consultations require three out of three areas of history, exam, and medical decision making (MDM) be met for code selection. Because of this, the following E/M codes require the documentation of a complete ROS:

For New Patients:

If you use the following CPT® codes:

99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity

99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity

99305 Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity

99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity

99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity

99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity

99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity

99220 Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity

Ten individual systems MUST be documented in the medical record. There is an alternative which allows for the documentation of pertinent positives with the notation “all other systems negative,” but this practice is no longer favored by The Centers for Medicare & Medicaid Services (CMS) and is under review for deletion or modification.

For Consultations:

If you use CPT® codes 99244 Office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity or 99245 Office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity, 10 individual systems MUST be documented in the medical record and the “all other systems negative” disclaimer applies.

For ER Patients:

If you use CPT® codes 99284 Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of moderate complexity or 99285 Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity, 10 individual systems MUST be documented in the medical record and the “all other systems negative” disclaimer applies.

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