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"CODE THIS!" (Case of the Month)

The Review of Systems

The Missing Link To Achieving The Elusive “Comprehensive” History”

by Lori-Lynne A. Webb, CPC and Renée Allen, MD, MHSc., FACOG

January, 2018

Most OB Hospitalist practices have a template that covers the 12 body systems for the review of systems (ROS) and for the physical exam section within the Electronic Medical Records (EMR) system. The “Evaluation and Services Management” publication, created and revised in 2017 by the Centers for Medicare and Medicaid Services (CMS), does not state a required number of negatives per system necessary for documentation. Instead, the publication directs you to document all positive and pertinent negative responses in the ROS section of the H&P.

According to this CMS guide; “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. Individual documentation is required of those systems with positive or pertinent negative responses. For the remaining Systems, a notation indicating all other systems are negative is permissible. However, in the absence of such a notation, you must individually document at least ten systems.” 

An important issue for OB Hospitalists is, how many systems were reviewed and what level of acuity does our documentation support?

Below are the systems that make up the ROS. To achieve a “complete” or “comprehensive” ROS review, at least ten (10) of these systems need clear documentation within the medical record for that specific encounter.

Take note that there are 14 body systems listed. Thus, 10 of the 14 must be documented to qualify for a “comprehensive” ROS.

  1. ™ ™Constitutional Symptoms (for example, 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

The ROS is a critical component of our documentation. Given the focused nature of many of our patient encounters in a triage or OBED, we likely aren’t going to be assessing very many systems. The complexity of our encounters are often determined by our medical decision making.

Usage of statements such as “ROS negative” or “negative other than in the HPI” is unacceptable and does not support the required documentation for a ROS when documenting the history portion of the encounter. 

While it is acceptable to use verbiage in the documentation such as, “all body systems were reviewed and are negative.” If you employ this statement in your clinical documentation, make sure you are indeed performing a 10-plus system review and that the review is pertinent to the patient’s chief complaint and HPI. Querying systems that have no relevance to the HPI is not considered appropriate practice. If you are currently using statements such as “ROS negative” or “negative other than in the HPI”, such statements only cover those systems described in your HPI and are not adequate documentation of 10 systems.

CMS notes in their recommendations for documentation of the patients’ history additional useful tips on the proper Documentation of History (click here)

  • 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
- 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 the 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.

  • If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or the other circumstance which precludes obtaining a history.

Example of proper ROS “comprehensive” documentation with a List by Body System for a Laboring Patient

GENERAL: The patient denies any recent weight loss or gain.  She had no fevers or chills. Denies any recent illnesses.  Denies headaches
EYES: Patient denies any diplopia, vision changes
ENT: Patient denied earache, tinnitus.
CARDIOVASCULAR: Patient denies any chest pain, palpitations or flutters.
RESPIRATORY:  Patient denies any shortness of breath, coughing or wheezing.
GASTROINTESTINAL:  Patient denies any nausea, vomiting or diarrhea.  She has had no hematochezia. 
GENITOURINARY:  The patient denies any frequency, hesitancy, urgency or dysuria. The patient does admit to having contractions that she says have been coming regularly since this morning.  She does admit to vaginal bleeding that she describes as excessive.
EXTREMITIES:  The patient denies any increased swelling or edema.
PSYCHIATRIC:  Patient denies any history of anxiety or depression.
ALLERGIES: Patient denies medication allergies, but does admit to having an allergy to cats.

Example of proper ROS “comprehensive” documentation with a Statement for a Patient with Persistent UTI:

REVIEW OF SYSTEMS: 10 body systems reviewed and are negative, except the patient still reports dysuria and polyuria. The patient has a recent diagnosis of UTI and has not yet completed her antibiotic regimen with Macrobid.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 CM/PCS Ambassador/Trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail  or you can also find current coding information on her blog site:

Dr. Renée Allen served co-author of this column. She is the SOGH Liaison to the ACOG Committee on Health Economics and Coding and Co-Chair of the Development Committee.  She currently works as an OB/GYN Hospitalist with Mednax/Obstetrix at Eastside Medical Center in Snellville, Georgia.

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