Know Review of Systems for More Accurate Coding
Both the 1995 and 1997 Evaluation and Management Documentation Guidelines define a review of systems (ROS) as an account of body systems obtained through a series of questions seeking to spot signs and symptoms that the patient may be experiencing, or has experienced. This query is made by the physician and/or the staffs verbally, or via a patient intake form, to define the patient’s total problem. It includes defining the need for an extended examination, testing, and possible effective management options.
The review may be about the systems directly related to the problems identified in the history of present illness, and additional body systems. The review of symptoms may be supplied in any format, including a separate patient intake or questionnaire form. It commonly is interspersed with elements of the HPI. There is a fine line between the signs and symptoms that the patient shares in the HPI, and those obtained via the ROS.
The review of systems is distinct. For example, if the documentation read, “The patient states she has a sore throat,” credit would not be given to both the HPI location and to the review of the ENT system. But if the documentation specifies, “The patient states that she has a sore throat. She denies any postnasal drip or fullness in her ears when she swallows,” there is a distinct component of both the HPI and a separate ENT system review.
Review of systems elements typically reference signs and symptoms of which both positive and negative comments are considered. Auditors commonly watch for indicators of a question that has been asked by the physician or provider and answered by the patient (for example, “the patient denies fever” or “upon further questioning, the patient said…”).
Review of systems should be medically necessary. It may be considered necessary to obtain a complete ROS when a patient presents as an initial new patient. It may not be considered medically necessary to repeat that complete review on every follow up. For purposes of review of systems, the following 14 systems are recognized.
- CONSTITUTIONAL: These are patient’s answers about general constitutional signs or symptoms. Some examples may be fatigue, exercise intolerance, fever, weakness, and impaired ability to carry out functions of daily living.
- EYES: These are the patient’s answers about signs or symptoms that may include the use of glasses, eye discharge, eyes itching, tearing or pain, spots or floaters, blurred or doubled vision, twitching, light sensitivity, swelling around the eyes or lids, and visual disturbances.
- EARS, NOSE, and THROAT: These are the patient’s answers about signs or symptoms including sensitivity to noise, ear pain, ringing in the ears, vertigo, feeling of fullness in the ears, ear wax, and abnormalities. It could include nose bleed, postnasal drip, frequent sneezing, frequent nasal drainage, impaired ability to smell, sinus pain, difficulty breathing, history of sinus infection and treatment. For the throat and mouth, sore throat, current or recurrent mouth lesions, teeth sensitivity, bleeding gums, history of hoarseness, change in voice quality, difficulty in swallowing or inability to taste.
- CARDIOVASCULAR: These are answers by the patient regarding signs and symptoms which may include chest pain, tightness, numbness, palpitations, heart murmurs, irregular pulse, color changes in the fingers or toes, edema, leg pain when walking.
- RESPIRATORY: These are patient’s answers about signs or symptoms of the respiratory system. Some examples may be cough, phlegm, chest pain on deep inhalation, wheezing, shortness of breath, difficulty breathing.
- GASTROINTESTINAL: These are patient’s answers about signs or symptoms of the GI system and include such things as indigestion or pain associated with eating, burning sensation in the esophagus, frequent nausea and/or vomiting, abdominal swelling, changes in bowel habits or stool characteristics such as diarrhea or constipation.
- GENITOURINARY: These are the patient’s answers about signs or symptoms of the genitourinary system. Some examples include painful urination, urine characteristics, urinary patterns, hesitance, flank pain, decreased or increased output, dribbling, incontinence, frequency at night, genital sores, erectile dysfunction, irregular menses, toilet training, or bed wetting.
- MUSCULOSKELETAL: Examples include muscle cramps, twitching or pain, limitations on walking, running, or participation in sports, joint swelling, redness or pain, joint deformities, stiffness, and noise with joint movement.
- INTEGUMENTARY: These are patient’s answers about signs or symptoms of the skin. Some examples may be itching, rash, skin reactions to hot and cold, changes of scars, moles, sores, lesion, nail color or texture, breast pain, tenderness or swelling, breast lumps, history of nipple discharge or changes.
- NEUROLOGICAL: These are patient’s answers about signs or symptoms of the neurologic system. Examples include numbness, tingling, dizziness, fainting or unconsciousness, seizures or convulsions, memory loss, attention difficulties, hallucinations, disorientation, speech or language dysfunction, inability to concentrate, sensory disturbances, motor disturbances including the gait, balance, and coordination, tremor or paralysis.
- PSYCHIATRIC: These are patient’s answers about signs or symptoms of the psychiatric system. Some examples include depression, excessive worrying, stress, suicidal thoughts, persistent sadness, anxiety, loss of pleasure from usual activities, loss of energy, physical problems that do not respond to treatment, restlessness, irritability, excessive mood swings.
- ENDOCRINE: These are patient’s answers about signs or symptoms of the endocrine system. Some examples maybe blood sugar readings at home, sudden changes in height and/or weight, increased appetite or thirst, intolerance to heat or cold, changes in hair distribution or skin pigment.
- HEMATOLOGIC/LYMPHATIC: Examples includeeasy bruising, fevers which come and go, swollen glands, night sweats, unusual bleeding.
- ALLERGIC/IMMUNOLOGIC: Examples include answers about allergies to medication, foods or other substances, hives and/or itching, frequent sneezing, chronic or clear postnasal drip, conjunctivitis, history of chronic infection, etc.
There are four levels of history which are referenced by the CPT® code book, but there are three types of review of systems:
- Problem pertinent is the review of one system
- Extended is the review of two to nine systems
- Complete is the review of 10 or more systems