Key on Components for Accurate ROS Count

Posted on 17 Dec, 2015 |comments_icon 2|By Chris Boucher
ros-level-em-code-possible

Higher-level E/Ms possible with complete ROS.

When your physician provides an evaluation and management (E/M) service, a vital part of the history component is the review of systems (ROS).

In short: There are three levels of ROS, and your level of ROS coding will need to be spot on if you’re to choose the proper code.

Consequences: If you choose the wrong ROS level, you could end up undercoding an E/M service —  which could lead to coding an E/M with lower relative value units (RVUs) than you rightfully deserve.

Check out this quick ROS guide to help you sort out the tangle of the three ROS levels, and code for the highest-RVU E/M code possible.

Follow CPT® Definition for ROS

According to CPT® 2015, an ROS is an inventory of body systems the provider obtains through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced.

This review helps define the patient’s problem, and put management options more clearly into focus for the provider.

For ROS coding purposes, CPT® identifies the following systems:

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

See also: Want to Get Paid for ACP? Medicare Ruling Means You Could in 2016

Also for ROS coding purposes, CPT® identifies the following ROS levels:

Problem-pertinent: This ROS level occurs when the provider reviews a single system during an E/M encounter. For example, a patient presents complaining of stomach pain, and the physician documents that he reviewed the gastrointestinal system.

Extended: This ROS level occurs when the provider asks the patient about two to nine systems during an E/M encounter. During an extended ROS, the provider asks the patient about the system related to the problem from the history of present illness (HPI) and several other systems. For example, a patient presents complaining of stomach pain, and the physician documents that he reviewed the gastrointestinal system, along with constitutional symptoms, and a check of the cardiovascular and musculoskeletal system.

Complete: This ROS level occurs when the provider asks the patient about the system[s] related to the presenting problem, plus all other additional body systems. For example, a patient presents complaining of stomach pain, and the physician documents that he reviewed the gastrointestinal system and all of the other systems listed above during the encounter.

Author

Chris Boucher


Chris Boucher has nearly 10 years of experience writing various newsletters and other products for The Coding Institute. His blog will cover several areas of coding and compliance, including CPT® coding, modifiers, HIPAA compliance and ICD-10 coding.

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