is hpi required for e/m?

System review, or review of systems (ROS), is the part of an E/M history that involves asking about body systems to identify past and present signs and symptoms. A series of questions helps define the problem, clarify the differential diagnosis, identify testing needed, and provide baseline data about body systems related to treatment options.

The body systems listed by both the CPT® guidelines and CMS 1995 and 1997 Documentation Guidelines are the same and are shown below.

Body Systems for ROS in E/M Coding

The CPT® E/M guidelines refer to problem pertinent system review, “problem pertinent system review extended to include a review of a limited number of additional systems,” and “review of systems that is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems.”

For Medicare, these translate to problem pertinent, extended, or complete ROS. The 1995 and 1997 Documentation Guidelines define these terms:

Comprehensive history: The documentation has to show a chief complaint, an extended HPI, a complete ROS, and a complete PFSH to reach a comprehensive history.