The Review of Systems

 (ROS) is an inventory of specific body systems performed in the process of taking a history from the patient.  The ROS is designed to bring out clinical symptoms which the patient may have overlooked or forgotten.  In theory, the ROS may illuminate the diagnosis by eliciting information which the patient may not perceive as being important enough to mention to the physician.  The rules for documenting the ROS are identical for both the 1995 and 1997 E/M guidelines.

There are fourteen individual systems recognized by the E/M guidelines:

1. Constitutional (e.g., fever, weight loss)

2. Eyes

3. Ears, Nose, Mouth, Throat

4. Cardiovascular

5. Respiratory

6. Gastrointestinal

7. Genitourinary

8. Musculoskeletal

9. Integumentary (skin and/or breast)

10. Neurological

11. Psychiatric

12. Endocrine

13. Hematologic/Lymphatic

14. Allergic/Immunologic 

Coding Tip: There are no specific rules about how much to ask the patient about each system.  This is left up to the discretion of the individual examiner.

There are three levels of ROS recognized by the E/M guidelines:

1. Problem Pertinent ROS : Requires review of ONE system related to current problem(s)

2. Extended ROS: Requires review of TWO to NINE systems

3. Complete ROS: Requires review of at least 10 systems 

Coding Tip: When documenting the ROS , it is not necessary to list each system individually.  It is acceptable to document a few pertinent positive or negative findings and then say: “All other systems were reviewed and are negative.”

Coding Tip: It is not necessary that the physician personally perform the ROS.  It is acceptable to have your staff record the ROS or to let the patient fill out an ROS questionnaire.  However, the physician MUST review the information and comment on pertinent findings in the body of the note.  In addition the physician should initial the ROS questionnaire and maintain the form in the chart as a permanent part of the medical record. 

Coding Tip: Many physicians overlook the fact that many follow-up encounters DO require a ROS.  There is a perception that a ROS only needs to be done during your initial encounter with the patient, but this is not correct.  For example, an extended ROS is required for a level 3 hospital progress note or a level 4 office follow-up visit with an established patient. 

Coding Tip: You DO NOT need to re-record a ROS if there is an earlier version available on the chart.  It is acceptable to review the old ROS and note any changes.  In order to use this shortcut, you must note the date and location of the previous ROS and comment on any changes in the body of the current note.  For example, if you are seeing an established patient in the office you can say: “Complete ROS which was performed during a previous encounter was re-examined and reviewed with the patient.  There is nothing new to add today.  For details, please refer to my previous note in this chart, dated 9/23/2012 .” 

Coding Tip: The ROS may be recorded separately or may be documented within the HPI.