Review of Systems (ROS) Calculation for E&M Coding

The ROS information factors into the calculations under the 95 or 97 Coding Guidelines. All ROS symptoms are shared fields from the Symptom Master template or Symptom Master2 template. These fields are shared with both the History of Present Illness and Review of Systems templates. By using a single shared table, you do not have to reenter symptoms on a Review of Systems template if they were documented on a History of Present Illness template. For example, if positive for “fever” has been entered on a History of Present Illness template, it has also been filled on the appropriate Review of Systems template and appears in the ROS data grid.

You can copy the previous review of systems information to the current encounter, click ROS History. The Historical Information window opens, click Copy ROS & Close to copy previous review of systems information to the current encounter on the SOAP template.

You can give the E&M coding credit for ROS to the symptom from a History of Present Illness or Review of Systems template. Your practice can select the preferred calculation method on the Practice Configuration template.

Two options are available:

• HPI and ROS credit is given when symptoms are entered on HPI templates - Symptoms documented in the History of Present Illness (HPI) appear in the Review of Systems template. The application gives HPI and ROS E&M coding credit for these symptoms. The symptoms print in both the HPI and ROS sections of the document.
  Note: The ROS coding credit is not given when symptoms have been entered on the dynamic HPI templates.
  

  

• ROS is assigned when symptoms are documented on ROS templates - Symptoms documented in the HPI appear in the Review of Systems template; however, symptoms must be documented on the Review of Systems template for the ROS E&M coding credit to be given.

  Symptoms only documented on the Review of Systems template only print in the ROS section of the document.

Each symptom field on the Symptom_Master and Symptom_Master 2 templates has been assigned an EM Bullet ID on the E&M Bullets and Field Mapping system template. For more information, go to NextGen Healthcare Success Community, and download the latest E&M Bullets and Field Mapping System Template for NextGen® Adaptive Content Engine. The Finalize template and the Coding OPH template for NextGen® Adaptive Content Engine , 8.4.3 or earlier, contain a stored procedure and additional triggers that total the field mappings for each system and calculate the total number of systems for the ROS component of E&M Coding.

NextGen Healthcare recommends that you do not customize the Symptom_Master and Symptom_Master 2 templates. To request that new symptoms be added to the templates, log a NextGen Healthcare Client Support ticket.