tci General Surgery Coding Alert - 2011 Issue 7

Reader Question: 'Complete' ROS Considers All Systems

Question: For a level 4 or 5 new patient E/M, I've heard mixed reports about what constitutes a complete review of systems (ROS). Does a complete ROS require that the surgeon review at least 10 systems, or must the review include all 14?California SubscriberAnswer: The review should include all 14 systems to achieve a complete ROS. A complete ROS can support a level four or five new patient E/M or consultation (99204-99205, Office or other outpatient visit..., or 99241-99245, Office consultation ...) or a level five established patient visit (99215, Office or other outpatient visit ...).Your confusion...

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