General Surgery Coding Alert

Question: What are the differences among ROS levels?

California Subscriber Answer: Four review of systems (ROS) levels contribute to the level of history selected for an E/M service. ROS progresses from -nonavailable- to -problem-pertinent- to -extended- and -complete.-
 
In a problem-pertinent ROS, the physician asks questions about the system directly related to the problem identified in the history of present illness (HPI).
 
When the physician asks about a limited number of additional systems, he meets the criteria for an extended ROS.
 
Important: Documentation must include positive responses and pertinent negatives for two to nine systems, according to the 1995 Documentation Guidelines for E/M Services.
 
A complete ROS requires asking about all body systems. The physician must review at least 10 organ systems and individually document those systems with positive responses and pertinent negatives.

Tip: For the remaining systems, the surgeon can use a notation to indicate that all other systems are negative.  -- Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.