Medical coding – REVIEW OF SYSTEMS (ROS)

Review of Systems


ROS is an inventory of body systems obtained by asking a series of questions to identify signs and/or symptoms that the patient may be experiencing or has experienced. The  following systems are recognized for ROS purposes:


* Constitutional Symptoms (for example, fever, weight loss);


* Eyes;


* Ears, Nose, Mouth, Throat;


* Cardiovascular;


* Respiratory;


* Gastrointestinal;


* Genitourinary;


* Musculoskeletal;


* Integumentary (skin and/or breast);


* Neurological;


* Psychiatric;


* Endocrine;


* Hematologic/Lymphatic; and


* Allergic/Immunologic.


The three types of ROS are problem pertinent, extended, and complete.


A problem pertinent ROS inquires about the system directly related to the problem identified in the HPI.


In the following example, one system – the ear – is reviewed:


* CC: Earache.


* ROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness, or headache.


An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems.


In the following example, two systems – cardiovascular and respiratory – are reviewed:


* CC: Follow-up visit in office after cardiac catheterization. Patient states “I feel great.”


* ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of left leg.


A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of ten) organ systems. You must individually document those systems with positive or pertinent negative responses. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, you must individually document at least ten systems.


In the following example, ten signs and symptoms are reviewed:


* CC: Patient complains of “fainting spell.”


* ROS:


• Constitutional: Weight stable, + fatigue.


• Eyes: + loss of peripheral vision.


• Ear, Nose, Mouth, Throat: No complaints.


• Cardiovascular: + palpitations; denies chest pain; denies calf pain, pressure, or edema.


• Respiratory: + shortness of breath on exertion.


• Gastrointestinal: Appetite good, denies heartburn and indigestion. + episodes of nausea. Bowel movement daily; denies constipation or loose stools.


• Urinary: Denies incontinence, frequency, urgency, nocturia, pain, or discomfort.


• Skin: + clammy, moist skin.


• Neurological: + fainting; denies numbness, tingling, and tremors.


• Psychiatric: Denies memory loss or depression. Mood pleasant.




Past, Family, and/or Social History


PFSH consists of a review of three areas:


* Past history includes experiences with illnesses, operations, injuries, and treatments;


* Family history includes a review of medical events, diseases, and hereditary conditions that may place the patient at risk; and


* Social history includes an age appropriate review of past and current activities.


The two types of PFSH are pertinent and complete.


A pertinent PFSH is a review of the history areas directly related to the problem(s) identified in the HPI. The pertinent PFSH must document at least one item from any of the three history areas.


In the following example, the patient’s past surgical history is reviewed as it relates to the identified HPI:


* HPI: Coronary artery disease.


* PFSH: Patient returns to office for follow-up of coronary artery bypass graft in 1992.


Recent cardiac catheterization demonstrates 50 percent occlusion of vein graft to obtuse marginal artery.


A complete PFSH is a review of two or all three of the areas, depending on the category of E/M service. A complete PFSH requires a review of all three history areas for services that, by their nature, include a comprehensive assessment or reassessment of the patient.


A review of two history areas is sufficient for other services.


You must document at least one specific item from two of the three history areas for a complete PFSH for the following categories of E/M services:


* Office or other outpatient services, established patient;


* ED;


* Domiciliary care, established patient;


* Subsequent NF care (if following the 1995 documentation guidelines); and


* Home care, established patient.


You must document at least one specific item from each of the history areas for the following categories  of E/M services:


* Office or other outpatient services, new patient;


* Hospital observation services;


* Hospital inpatient services, initial care;


* Comprehensive NF assessments;


* Domiciliary care, new patient; and


* Home care, new patient.


In the following example, the patient’s genetic history is reviewed as it relates to the current HPI:


* HPI: Coronary artery disease.


* PFSH: Family history reveals the following:


• Maternal grandparents – Both + for coronary artery disease; grandfather: deceased at age 69; grandmother: still living.


• Paternal grandparents – Grandmother: + diabetes, hypertension; grandfather: + heart attack at age 55.


• Parents – Mother: + obesity, diabetes; father: + heart attack at age 51, deceased at age 57 of heart attack.


• Siblings – Sister: + diabetes, obesity, hypertension, age 39; brother: + heart attack at age 45, living.


Notes on the Documentation of History


* You may list the CC, ROS, and PFSH as separate elements of history or you may include them in the description of the HPI;


* You do not need to re-record a ROS and/or a PFSH obtained during an earlier encounter if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in
an institutional setting or group practice where many physicians use a common record. You may document the review and update by:


• Describing any new ROS and/or PFSH information or noting there is no change in the information; and


• Noting the date and location of the earlier ROS and/or PFSH;


* Ancillary staff may record the ROS and/or PFSH. Alternatively, the patient may complete a form to provide the ROS and/or PFSH. You must provide a notation supplementing or confirming the information recorded by others to document that the physician reviewed the information; and * If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history.