Expert Article: Controversy in the CMS DG Requirements for Documentation of a Complete ROS

Recently, controversy has arisen related to interpretation of documentation guidelines and language used to warrant a complete Review of Systems. The controversy stems from the use of the “all systems negative” prompt that most providers document to indicate a complete review of systems when coupled with documentation of pertinent system negatives and positives.  At least one MAC is currently requiring documentation of a minimum of ten systems; this MAC is not accepting less than documentation of ten systems that have pertinent negative and positive findings, along with the statement “all other systems negative” for a complete Review of Systems. This results in down-coding of records that would otherwise qualify for application of E/M code 99285, to E/M code 99284. It is our position that this is an incorrect interpretation, and the long-standing requirements published in the CMS 1995 Documentation Guidelines for Evaluation and Management Services (1995 DGs) should be utilized as the 1995 DGs permit use of this statement provided it is accompanied by documentation of the review of pertinent systems to create a complete Review of Systems. 

For the last 24 years, physicians of all specialties have relied on the 1995 or the 1997 DGs to quantify documentation requirements for key chart components (i.e., history, examination, and medical decision-making). The DGs provide rules about what providers need to document for coders to assign the appropriate E/M level. Coders use the criteria as written in the DGs to count the requirements for the levels of history, exam, and medical decision-making, enabling them to choose a proper Evaluation and Management level.  

There are 14 systems that can be documented in the Review of Systems (ROS). Both the 1995 DGs and the recent Evaluation and Management Services guide published by the Medicare Learning Network (MLN) in August 2017 both include the following 14 systems:  

  1. Constitutional symptoms (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 

While the 14 systems are identical in both documents, variations in the language that describe the different ROS levels have created some concerns.

Problem Pertinent ROS

Regarding a Problem Pertinent ROS, page 7 of the 1995 DGs states:

A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI. DG: The patient’s positive responses and pertinent negatives for the system related to the problem should be documented. 

Page 7 of the Medicare Learning Network’s Evaluation and Management Services document states:    

A problem pertinent ROS inquires about the system directly related to the problem identified in the HPI. 

In this example, one system – the ear – is reviewed:

  • CC: Earache. 
  • ROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness, or headache. 

 

Definitions of the Problem Pertinent ROS in both documents are similar, and have not resulted in dispute.

Extended ROS

Regarding an Extended ROS, page 7 of the 1995 DGs states:

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems. DG: The patient’s positive responses and pertinent negatives for two to nine systems should be documented. 

Page 7 of the Medicare Learning Network’s Evaluation and Management Services document states:    

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems. 

In this example, two systems – cardiovascular and respiratory – are reviewed: 

 

  • CC: Follow-up visit in office after cardiac catheterization. Patient states “I feel great.” 
  • ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of left leg. 

 

There are subtle differences between the definitions in the documents that have resulted in debate. The 1995 DGs limit the total requirement to positive responses and pertinent negatives for a defined two to nine systems from the problem(s) identified in the HPI and systems review in the ROS. The language in the MLN document is different in that it can be interpreted to require any system(s) documented in the HPI PLUS documentation of two to nine additional systems in the ROS. 

Complete ROS

Regarding a Complete ROS, page 8 of the 1995 DGs states:

A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems. 

DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.

In summary, the DGs permit providers some leeway in documenting this important section of the chart. Referring to the definition above, providers would meet the requirements for a complete ROS by documenting either of the following:

  1. Ten of the 14 organ systems.
  2. Documentation of up to ten systems where positive or pertinent negative responses are revealed during historical questioning of the patient, followed by a statement similar to “all other systems are negative”.

Page 7 of the Medicare Learning Network’s Evaluation and Management Services document states:    

 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. You must individually document those systems with positive or pertinent negative responses. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, you must individually document at least ten systems.

There is a difference between these two definitions in that the 1995 DGs limit the total requirement to positive responses and pertinent negatives for up to ten systems that need to be documented from problems in BOTH the HPI and systems review in the ROS. The MLN’s document is different in that it requires any system documented in the HPI PLUS ten additional systems to be documented in the ROS in addition to the documented HPI systems. 

Confusion also exists regarding the statement “all other systems are negative”.  The MLN definition is being interpreted to mean that this statement (“all other systems are negative”) can only be used AFTER the provider has documented all systems mentioned in the HPI, PLUS a minimum of ten organ systems from the ROS. This interpretation creates additional requirements that would mandate documentation of 14 systems when, as an example, four systems are mentioned in the HPI which would then require an additional 10 more systems to achieve a complete ROS. Using the 1995 DGs, if four systems are documented in the HPI, only an additional six would be required to have 10 total systems for the ROS. If the provider documented systems with pertinent positives or negatives that totaled less than ten combining both the HPI systems and the ROS systems, adding the phrase “all other systems are negative” would suffice in achieving a complete ROS. 

The requirement in the MLN document is much more demanding of the providers and should be changed to be consistent with the 1995 DGs requirement. In this manner, educational programs can continue to teach what has been accepted for over 24 years, thus allowing appropriate documentation without additional changes that will add more burden to the already arduous process of proper chart documentation.

Review of the comprehensive history section of the CPT E/M Code 99285 “Fact Sheet” has also raised several concerns that should be addressed. The following modifications should be considered to reduce the burden associated with the complexity and ambiguity of the current guidelines, and align E/M coding and documentation with the current practice of emergency medicine:

  1. “Reason for admission” would be better defined as “Chief complaint” since “Reason for admission” implies that admission to the hospital is a requirement to code 99285. In fact, ED providers often order extensive work-ups and therapy on various patients, and then subsequently discharge patients following successful therapeutic intervention in the ED. Examples of these types of cases are patients presenting with abdominal pain, chest pain, shortness of breath, and changing mental status whose work-ups and therapy may end in patient discharge. These chief complaints, however, still require complex decision-making intended to confirm or rule out significant diagnoses. These types of cases regularly qualify for proper application of E/M code 99285.
  2. The reference to a Problem Pertinent Review of Systems as a requirement for proper application of code 99285 is incorrect. The requirement for 99285 mandates a complete Review of Systems which, as published in the CMS 1995 DGs, “inquires about the system(s) directly related to the problem(s) identified in the HPI, plus all additional body systems and specifically requires that at least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.”
  3. The section stating: “Medically necessary review of ALL body systems history” is also incorrect. To repeat, the requirement for 99285 mandates a complete Review of Systems which, as published in the CMS 1995 Documentation Guidelines, “inquires about the system(s) directly related to the problem(s) identified in the HPI, plus all additional body systems and specifically requires that at least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.”
  4. The reference to a medically necessary, complete past, family, and social history is also incorrect. Page 8 of the 1995 DGs states the following: “A complete PFSH (Past, Family, Social History) is a review of two or all three of the PFSH history areas.

DG: At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office and other outpatient services, established patient; emergency department services; subsequent nursing facility care; domiciliary care, established patient: and home health, established patient.”

  1. The following sections are correct as published, and do not require revision:
    1. The definition of 99285 under “Emergency Department Visit” section.
    2. HPI – History of Present Illness section.
    3. Chief Complaint section
    4. Review of Systems section that includes the 14 systems. 
    5. Past, Family and/or Social History (PFSH) section that gives examples of items that the provider may include in the either the Past, Family or Social histories. 


Consistency amongst interpretations of the language in the 1995 Documentation Guidelines for Evaluation and Management Services published by CMS, and the Evaluation and Management Services guide published by the Medical Learning Network, is critical lest differences in industry understanding promulgate confusion, and put undue burden on providers and coders alike. Uniformity is critical, and will foster continuation of sound documentation educational programs, and Quality Assurance and compliance program development and implementation.

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