Avoid downcoding by documenting a review of systems

Cracking the Code

Dirk Elston

Dr. Elston, who serves as director of the Ackerman Academy of Dermatopathology in New York, has served on the AMA-CPT Advisory Committee.

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The review of systems (ROS) is the most common portion of the history that clinicians forget to document. This can result in downcoding of an evaluation and management (E/M) visit. All E/M levels above a new patient level one (N1, 99201) require a ROS, as well as the levels above an established patient level two visit (E2, 99212) if history is being used as one of the two required components to satisfy the documentation of an established visit.

The Centers for Medicare and Medicaid Services (CMS) defines the ROS as “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.” Organ systems, rather than bullets, are counted, so if the patient is asked about other rashes or skin lesions, this counts as a single organ system. Likewise, “fevers, chills, and weight loss” count as a single system (constitutional symptoms). As with other elements of the history, it is only appropriate to document questions that are relevant to the visit.

At least one question should relate to the same organ system as the presenting complaint. For dermatologists, this would, of course, be the skin. There are very few visits where it would not be appropriate to ask about a history of new or changing moles. [pagebreak]

For purposes of ROS, CMS recognizes the following systems:

  • Constitutional symptoms
  • (e.g., fever, weight loss)
  • Eyes
  • Ears, nose, mouth, throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Integumentary (skin and/or breast)
  • Neurological
  • Psychiatric
  • Endocrine
  • Hematologic/lymphatic
  • Allergic/immunologic

A problem-pertinent ROS inquires about the system directly related to the problem(s) identified in the history of present illness (HPI). Both positive and negative responses should be documented. An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems (two nine additional systems). A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems. While at least 10 organ systems must be reviewed, only positive and pertinent negative responses need to be documented. For the remaining systems, a notation indicating “all other systems are negative” may be permissible. Check with your local carrier.

A quick translation of the above is that for an N2 (99202) or E3 (99213) E/M visit, at least one question related to the skin should be documented. For an N3 (99203) or E4 (99214) E/M visit, at least two organ systems (including one question related to the skin) should be documented. For an N4 (99204) or E5 (99215) E/M visit, at least one question related to the skin should be documented specifically along with a statement that “all other systems were negative,” assuming that the questions were appropriate to the visit, in fact, asked, and allowed by the carrier.

A brief review of the required history elements for each level of service is available here.