Pediatric Coding Alert

Three scenarios, three ROS levels; do you know which is which?

Coders that can quickly and accurately identify review of systems (ROS) level are a huge benefit to their practices, as you need a quick mind and an even quicker eye to spot systems and documentation of their reviews.

Three scenarios follow, each with a different ROS level; one is problem-pertinent, one is extended, and one is complete. Read the scenarios, identify the ROS level, and turn to page 22 for the answers and explanation.

One more thing: Give yourself extra credit — or a self-congratulatory high-five — if you successfully identify all of the systems in each ROS scenario. Good luck!

Scenario 1: From Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb.:

Patient presents with a chief complaint (CC) of upper respiratory symptoms including nasal discharge and earache. The patient’s mother is also concerned about a recent panic attack the child suffered while flying. Medical record documentation supports history of present illness (HPI), current medications, past medical and social history and allergies.

Encounter notes include the following details:

• No recent weight change
• No vision problems
• Frequent sinus pain/pressure, worse during allergy season
• No nausea/vomiting
• No rash
• Panic attacks for a number of years, on lorazepam
• Denies shortness of breath, wheezing.

Scenario 2: 

Patient presents with a fever and weight loss. Encounter notes indicate that the provider took the patient’s temperature and weighed her.

Scenario 3: 

Patient presents complaining of recent hearing loss and a barking, recurring cough. Encounter notes indicate the following: 

• Px generally feeling well other than his recent hearing loss. 
• Appetite and weight stable.
• Denies recent fevers or night sweats.
• No throat pain or hoarseness.
• No headache or visual symptoms.
• Occasional cough and mild dyspnea. 
• Denies joint pain or any rashes.
• Denies nausea/vomiting. 
• No chest pain or lower-extremity edema. 

The remainder of his review of systems was negative, as recorded on his new patient health history form reviewed today with the patient. Please refer to complete ROS information on the form.