Wiki Reviewof Systems

[easumma]

I have a provider that is using this as ROS? on every visit... Then the visit is coded as a level 3 or 4. There is a full exam and HPI, due to the ROS would it get down coded?

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ROS: Denies F/C, neck pain, weight loss, cyanosis, CP, N/V, diarrhea, rash, joint pains, decreased urine output.

 

[Pathos]

I have a provider that is using this as ROS? on every visit... Then the visit is coded as a level 3 or 4. There is a full exam and HPI, due to the ROS would it get down coded?

*
ROS: Denies F/C, neck pain, weight loss, cyanosis, CP, N/V, diarrhea, rash, joint pains, decreased urine output.

Hello,

CMS states in their E/M guidelines that the "ROS is an inventory of body systems", so the focus is more on each system and is not counted twice is the symptom falls in a system that is already counted. For example, CMS also shows: "Cardiovascluar: + palpitations; denies chest pain; denies calf pain, pressure or edema" as one ROS examined.

To go back to the statement your provider provided, I would list them as follows:

Constitutional: Denies F/C, weight loss
Cardiovascular: Denies CP, cyanosis (could possibly be under Integumentary)
Gastrointestinal: Denies N/V, diarrehea
Urinary: Decreased urine output
Musculoskeletal: Denies neck pain (perhaps under ENMT), joint pains
Integumentary: Denies rash

I see 6 (maybe 7) ROS reviewed, however I can follow your provider's way of thinking. He/she got the 10 ROS elements, however some of the elements examined fall under the same categories.

However, ROS aside; you did not mention whether this patient is an Established or New Patient, which would directly impact the E/M level. Also, I didn't see anything mentioned about the Medical Decision Making either. Don't forget that all three E/M components (History, Exam and MDM) should be a part of any E/M visit.