General Surgery Coding Alert

Question: For a level 4 or 5 new patient E/M, I've heard mixed reports about what constitutes a complete review of systems (ROS). Does a complete ROS require that the surgeon review at least 10 systems, or must the review include all 14?

California Subscriber

Answer: The review should include all 14 systems to achieve a complete ROS. A complete ROS can support a level four or five new patient E/M or consultation (99204-99205, Office or other outpatient visit..., or 99241-99245, Office consultation ...) or a level five established patient visit (99215, Office or other outpatient visit ...).

Your confusion about 10 or more systems is understandable. CMS guidelines state that a complete ROS "inquires about the system(s) directly related to the problem(s) identified in the history of present illness (HPI) plus all additional ... organ systems."

Documentation varies: CMS gives you various ways you can document a complete ROS, as follows:

• Individually document all systems with positive or pertinent negative responses, plus add a notation indicating that all other systems are negative; OR
• Individually document at least 10 systems.

Although the latter documentation option doesn't require mention of all 14 systems, the expectation is that the physician reviewed all 14 and provided individual documentation for at least 10.

In terms of the documentation you'll look for when billing E/M services for your surgeon, this distinction won't matter -- at least 10 individually documented systems earns a complete ROS. But the distinction is important for the physician, who should review all 14 systems to justify a complete ROS.