Academy of Chiropractic’s Lawyers PI Program

Office Systems & Admissibility #23

From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP

“E & M: Review of Systems”

99203-99204-99205 Implications




As chiropractors, we are considered both specialists in neuro-musculoskeletal biomechanical treatment and a primary care provider concurrently. In addition, there are a myriad of comorbidities that can affect the diagnosis, prognosis and treatment plan in the neuro-musculoskeletal biomechanical / chiropractic environment. As a result, this is why we are trained as primary care providers… to ensure the safety of the public. As a result, it is my strongest recommendation to ALWAYS do a complete review of systems. As a result, you should consider doing a more complete examination and not be afraid to do a “3-4-5” level E & M because your level of involvement is higher. 

A patient filling out a form without you documenting that you reviewed the systems (and you should be documenting them in your evaluation) is no different than you NOT performing a review of systems. Short cuts are just that… the shortest way to failure and if this seems to burdensome, get an EMR system that will help you. However, you MUST perform a review of systems.

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. 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.  


Systems:  

  1. Constitutional Symptoms (for example, 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.

The following example reviews 10 systems:
  1. Constitutional: Weight stable, + fatigue.
  2. Eyes: + loss of peripheral vision.
  3. Ear, Nose, Mouth, Throat: No complaints.
  4. Cardiovascular: + palpitations; denies chest pain; denies calf pain, pressure, or edema.
  5. Respiratory: + shortness of breath on exertion.
  6. Gastrointestinal: Appetite good, denies heartburn and indigestion + episodes of nausea. Bowel movement daily; denies constipation or loose stools.
  7. Urinary: Denies incontinence, frequency, urgency, nocturia, pain, or discomfort.
  8. Skin: + clammy, moist skin.
  9. Neurological: + fainting; denies numbness, tingling, and tremors.
  10. Psychiatric: Denies memory loss or depression. Mood pleasant. 
CMS offers the following clarification: 

"The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others."

Therefore you may, to the letter of the interpretation, document that you reviewed the patient's intake forms in your evaluation and initial the form. HOWEVER... I do not support that short cut as I have never seen any other specialist take that route. In order to win at the highest level, you must take extraordinary measures to be the best with every detail. Not display shortcuts that are accommodated by an "*" with what is acceptable.