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March 9, 2010
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Four parts of a History
Chief Complaint (CC)
Timing
The time of day the patient
experienced the signs
and symptoms
8 Areas That Help Determine
HPI
Severity
Just how serious is the
patient‘s condition?
Duration
How long have the
patient's signs and symptoms
been present?
8 Areas That Help Determine
HPI
Modifying Factors
What the patient did to
alleviate pain or exacerbate
Dull
+Aching
1 quality
Let’s try it!
Est patient here today for sore throat (location) and productive
cough (associated signs and symptoms). Throat hurts worst at
night (timing) and is a 7 (severity)
Solution?
The physician documented four elements in the note. Four
elements counts as an extended HPI. For an established
patient visit, an extended HPI supports a level greater than
or equal to 99214. For a new patient visit code, extended
HPI supports an E/M level greater than or equal to 99203
provided the visit meets all other required elements as
well.
What Is ROS?
Physician reviews systems directly related
to the problem or problems identified in
the HPI portion of the E/M and a number of
additional systems.
CPT defines ROS as:
“an inventory of body systems obtained through a
series of questions seeking to identify signs
and/or symptoms that the patient may be
experiencing or has experienced.”
ROS “helps define the problem,
clarify the differential diagnosis,
identify needed testing, or serves
as baseline data on other systems
that might be affected by any
possible management options.”
Example:
A patient reports to the FP complaining of a headache.
The FP inquires about how long the headache has
lasted, and a few other questions to rule out migraines.
The FP discovers that the patient has not taken any
medication for the headaches, he prescribes several
over-the-counter options to deal with the condition, and
tells the patient to come back in for another exam if the
headaches worsen or increase in frequency.
In this instance, you can only consider 1 system
reviewed (neurological), since the FP has apparently
only inquired about the system directly related to
the problem.
Count These Systems
CPT identifies the following ROS
elements
What Are the Different ROS Levels?
Problem-pertinent: When the physician reviews one system, you
have a problem-pertinent ROS.
This ROS level can support up to a level-two new patient E/M
(99202, an expanded problem-focused history; an expanded
problem-focused examination; and straightforward medical
decision making) or a level-three established patient service
(99213, … an expanded problem-focused history; an expanded
problem-focused examination; medical decision-making of low
complexity).
What Are the Different ROS Levels?
Extended: When the physician reviews two to nine
systems, the encounter is an extended ROS.
Extended ROS can support up to a level-three new
patient service
(99203, … a detailed history; a detailed
examination; and medical decision-making of low
complexity) or level-four established patient
service (99214, … a detailed history; a detailed
examination; medical decision-making of
moderate complexity).
What Are the Different ROS Levels?
Complete: For a complete ROS, most insurers accept a
review of 10 or more systems with all others documented.
Per CPT, a complete ROS requires a review of all additional
body systems. This would include 14 systems. The CMS
Documentation Guidelines define a complete ROS as
covering at least 10 organ systems.
“A complete ROS inquires about the system(s) directly related to the
problem(s) identified in the HPI plus all additional body systems,”
the E/M Documentation Guidelines state.
With a complete ROS, reporting a 99204, 99205 or is possible --
depending on other encounter specifics.
Example:
An internist sees a patient with multiple chronic conditions:
COPD, CHF, hypertension, and diabetes. The physician asks
questions about 10 of the systems, including constitutional,
eyes, cardiovascular, respiratory, integumentary, neurological,
and endocrine. He documents the positive and pertinent
negative responses for 10 of the systems and writes: 10 of 14
systems obtained, remainder of systems are negative.
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Key # 3 of 3 3 of 3 3 of 3 3 of 3 3 of 3
Office Visits – Established
Patient
Codes 99211 99212 99213 99214 99215
Key # 2 of 3 2 of 3 2 of 3 2 of 3 2 of 3
Levels of History
Level of History Chief History of Present Illness Review of Systems (ROS) Past, Family, Social History
Complaint (HPI) (PFSH)
(CC)
CPT Medicare CPT Medicare CPT Medicare
Problem Focused Required Brief 1-3 elements Not Required Not Required