Review of systems documentation: Difference between revisions
(Expanded: added Background with 2023 CMS update, CMS organ systems list, Documentation Tips, psych system to sample, references, See Also, documentation pages template) |
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==Background== | ==Background== | ||
*Under the 2023 CMS E/M guidelines, the ROS is no longer a required element for determining ED billing level — billing is now driven by MDM or total time<ref>American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient and Other Services Code and Guideline Changes. 2023.</ref> | |||
*Under the 2023 CMS E/M guidelines, the ROS is | |||
*Despite this change, a focused ROS remains clinically valuable for capturing relevant symptoms and supporting the clinical narrative | *Despite this change, a focused ROS remains clinically valuable for capturing relevant symptoms and supporting the clinical narrative | ||
*CMS recognizes | *CMS recognizes 14 organ systems for ROS documentation | ||
*A "complete" ROS (≥10 systems) was historically required for Level 5 billing; this is no longer the case under current guidelines but may still be institutionally required | *A "complete" ROS (≥10 systems) was historically required for Level 5 billing; this is no longer the case under current guidelines but may still be institutionally required | ||
| Line 54: | Line 53: | ||
==See Also== | ==See Also== | ||
{{Documentation pages}} | {{Documentation pages}} | ||
Latest revision as of 19:04, 25 March 2026
Background
- Under the 2023 CMS E/M guidelines, the ROS is no longer a required element for determining ED billing level — billing is now driven by MDM or total time[1]
- Despite this change, a focused ROS remains clinically valuable for capturing relevant symptoms and supporting the clinical narrative
- CMS recognizes 14 organ systems for ROS documentation
- A "complete" ROS (≥10 systems) was historically required for Level 5 billing; this is no longer the case under current guidelines but may still be institutionally required
CMS-Recognized Organ Systems
- Constitutional
- Eyes
- Ears, Nose, Mouth and Throat
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Integumentary (skin and/or breast)
- Neurologic
- Psychiatric
- Endocrine
- Hematologic/Lymphatic
- Allergic/Immunologic
Sample ROS (Complete)
REVIEW OF SYSTEMS:
CONST: Negative for fever, body aches and chills.
HEENT: Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.
EYES: Negative for discharge/pain or vision changes.
RESP: Negative for cough/hemoptysis and shortness of breath.
CV: Negative chest pain, difficulty breathing, palpitations.
ABD: Negative pain, nausea, vomiting.
GU: Negative increased frequency, dysuria, blood in urine or stool.
MUSC: Negative for muscle aches, edema.
SKIN: Negative rash, lesions/sores.
NEURO: Negative headache, dizziness, weakness.
PSYCH: Negative for depression, anxiety, suicidal ideation.
Documentation Tips
- Document pertinent positives and negatives relevant to the chief complaint
- "All other systems reviewed and negative" is acceptable shorthand for non-pertinent systems after documenting specific positive/negative findings
- The ROS should be obtained from the patient (or caregiver), not the physician's exam findings
- Documenting the ROS in the HPI is acceptable as long as it is clearly identifiable
See Also
Documentation Pages
- General
- Components of the Medical Record
- Procedure and Reexamination
- Special Documentation
- Reference
References
- ↑ American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient and Other Services Code and Guideline Changes. 2023.