The Review of Systems Is a Component of the

Both the 1995 and 1997 Evaluation and Management Documentation Guidelines define a review of systems (ROS) as an account of body systems obtained through a series of questions seeking to spot signs and symptoms that the patient may be experiencing, or has experienced. This query is made by the physician and/or the staffs verbally, or via a patient intake form, to define the patient'due south total problem. It includes defining the need for an extended exam, testing, and possible effective direction options.
The review may be most the systems direct related to the issues identified in the history of present illness, and boosted torso systems. The review of symptoms may be supplied in any format, including a separate patient intake or questionnaire class. It commonly is interspersed with elements of the HPI. There is a fine line betwixt the signs and symptoms that the patient shares in the HPI, and those obtained via the ROS.
The review of systems is singled-out. For example, if the documentation read, "The patient states she has a sore pharynx," credit would non be given to both the HPI location and to the review of the ENT system. But if the documentation specifies, "The patient states that she has a sore throat. She denies whatsoever postnasal drip or fullness in her ears when she swallows," there is a singled-out component of both the HPI and a separate ENT system review.
Review of systems elements typically reference signs and symptoms of which both positive and negative comments are considered. Auditors unremarkably sentinel for indicators of a question that has been asked by the dr. or provider and answered by the patient (for example, "the patient denies fever" or "upon further questioning, the patient said…").
Review of systems should exist medically necessary. Information technology may be considered necessary to obtain a complete ROS when a patient presents every bit an initial new patient. It may not be considered medically necessary to repeat that complete review on every follow up. For purposes of review of systems, the following 14 systems are recognized.

1. Constitutional:These are patient'south answers well-nigh general constitutional signs or symptoms. Some examples may be fatigue, practise intolerance, fever, weakness, and dumb power to bear out functions of daily living.
2. EYES:These are the patient's answers well-nigh signs or symptoms that may include the utilize of glasses, eye discharge, eyes itching, trigger-happy or pain, spots or floaters, blurred or doubled vision, twitching, light sensitivity, swelling around the eyes or lids, and visual disturbances.
3. EARS, Nose, and Throat:These are the patient'south answers about signs or symptoms including sensitivity to noise, ear hurting, ringing in the ears, vertigo, feeling of fullness in the ears, ear wax, and abnormalities. It could include nose bleed, postnasal drip, frequent sneezing, frequent nasal drainage, impaired power to aroma, sinus pain, difficulty breathing, history of sinus infection and treatment. For the throat and mouth, sore throat, current or recurrent rima oris lesions, teeth sensitivity, bleeding gums, history of hoarseness, change in voice quality, difficulty in swallowing or inability to taste.
4. CARDIOVASCULAR:These are answers by the patient regarding signs and symptoms which may include chest pain, tightness, numbness, palpitations, center murmurs, irregular pulse, color changes in the fingers or toes, edema, leg pain when walking.
5. RESPIRATORY:These are patient's answers about signs or symptoms of the respiratory system. Some examples may be coughing, phlegm, chest pain on deep inhalation, wheezing, shortness of jiff, difficulty breathing.
6. GASTROINTESTINAL:These are patient'southward answers about signs or symptoms of the GI system and include such things equally indigestion or pain associated with eating, burning sensation in the esophagus, frequent nausea and/or vomiting, abdominal swelling, changes in bowel habits or stool characteristics such every bit diarrhea or constipation.
7. GENITOURINARY: These are the patient's answers nearly signs or symptoms of the genitourinary system. Some examples include painful urination, urine characteristics, urinary patterns, hesitance, flank pain, decreased or increased output, dribbling, incontinence, frequency at night, genital sores, erectile dysfunction, irregular catamenia, toilet training, or bed wetting.
8. MUSCULOSKELETAL: Examples include muscle cramps, twitching or pain, limitations on walking, running, or participation in sports, joint swelling, redness or pain, joint deformities, stiffness, and noise with joint movement.
9. INTEGUMENTARY:These are patient'south answers most signs or symptoms of the skin. Some examples may be itching, rash, skin reactions to hot and cold, changes of scars, moles, sores, lesion, smash color or texture, breast pain, tenderness or swelling, breast lumps, history of nipple belch or changes.
10. NEUROLOGICAL:These are patient's answers about signs or symptoms of the neurologic arrangement. Examples include numbness, tingling, dizziness, fainting or unconsciousness, seizures or convulsions, memory loss, attention difficulties, hallucinations, disorientation, voice communication or language dysfunction, disability to concentrate, sensory disturbances, motor disturbances including the gait, balance, and coordination, tremor or paralysis.
11. PSYCHIATRIC: These are patient's answers about signs or symptoms of the psychiatric system. Some examples include low, excessive worrying, stress, suicidal thoughts, persistent sadness, anxiety, loss of pleasure from usual activities, loss of free energy, concrete problems that do not respond to treatment, restlessness, irritability, excessive mood swings.
12. ENDOCRINE: These are patient's answers nigh signs or symptoms of the endocrine system. Some examples maybe blood sugar readings at habitation, sudden changes in height and/or weight, increased appetite or thirst, intolerance to heat or cold, changes in hair distribution or skin paint.
13. HEMATOLOGIC/LYMPHATIC: Examples includeeasy bruising, fevers which come up and go, swollen glands, night sweats, unusual bleeding.
14. ALLERGIC/IMMUNOLOGIC:Examples include answers about allergies to medication, foods or other substances, hives and/or itching, frequent sneezing, chronic or articulate postnasal drip, conjunctivitis, history of chronic infection, etc.

There are 4 levels of history which are referenced by the CPT® lawmaking book, but there are three types of review of systems:

• Problem pertinent is the review of ane system
• Extended is the review of 2 to nine systems
• Complete is the review of 10 or more systems

• Author
• Recent Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been roofing medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson Academy.

About John Verhovshek Has 575 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been roofing medical coding and billing, healthcare policy, and the business organization of medicine since 1999. He is an alumnus of York Higher of Pennsylvania and Clemson University.

owenswhoas1974.blogspot.com

Source: https://www.aapc.com/blog/45660-review-of-systems/

Share this post