Review of systems documentation

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

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.

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

↑ American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient and Other Services Code and Guideline Changes. 2023.

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