Gastroenterology Coding Alert

Question: A new patient reports to the gastroenterologist with heartburn, stomach ache, and nausea. She also reports a chronic cough and trouble swallowing. The physician's notes indicate that the patient does not have a fever, eye discharge, dysuria, headache, or a rash. The physician also notes that the patient reports anxiety, some pain in her right shoulder, and has urinary frequency. How should I code for this visit and does it meet the ROS requirement?Alabama SubscriberAnswer: This encounter does meet the review of system (ROS) requirement since the physician checked and documented a total of 10 systems as follows:heartburn, stomach ache, nausea (gastrointestinal)chronic cough (respiratory)trouble swallowing (ear, nose, mouth, throat)fever (constitutional)eye discharge (eyes)dysuria, urinary frequency (genitourinary)headache (neurological)rash (integumentary)anxiety (psychiatric)shoulder pain (musculoskeletal).Tip: Remember, you can only count a single system once. Even though gastrointestinal and genitourinary systems were mentioned more than once, they only count once each. If the documentation does [...]