CMS Level 5 Chart Review of Systems Requirements
According to CMS documentation guidelines, a level 5 evaluation and management (E/M) service requires a complete review of systems, which is defined as documentation of at least 10 organ systems.
Documentation Requirements for Level 5 E/M Services
The Centers for Medicare and Medicaid Services established specific documentation criteria for different levels of E/M services. For the highest complexity level (level 5), the review of systems component must meet the following threshold:
- A complete review of systems requires documentation of at least 10 organ systems 1
- This can be documented by individual notation of 10 systems, or by noting "all systems reviewed" with documentation of positive and pertinent negative findings 1
The 10+ Organ Systems to Document
When performing a complete review of systems for level 5 documentation, you must address at least 10 of the following body systems 1:
- Constitutional symptoms (fever, weight loss, night sweats, fatigue) 1
- Eyes (visual changes, disturbances) 1
- Ears, nose, mouth, throat (oral lesions, dysphagia, hearing changes) 1
- Cardiovascular (chest pain, palpitations, orthopnea, edema) 1
- Respiratory (cough, dyspnea, wheezing) 1
- Gastrointestinal (nausea, vomiting, abdominal pain, diarrhea, bowel habit changes) 1
- Genitourinary (urinary frequency, urgency, dysuria) 1
- Musculoskeletal (joint pain, stiffness, swelling, muscle weakness) 1
- Integumentary/skin (rash, lesions, discoloration, ulcers) 1
- Neurological (changes in neurological function, mental status) 1
- Psychiatric (depression, anxiety, mood changes) 1
- Endocrine (heat/cold intolerance, polyuria, polydipsia) 1
- Hematologic/lymphatic (bleeding, bruising, lymph node enlargement) 1
- Allergic/immunologic (allergies, immunodeficiency symptoms) 1
Clinical Documentation Strategy
The most efficient approach is to document "complete review of systems performed" followed by listing all positive findings and pertinent negatives, rather than individually documenting all 10+ systems 1. This method satisfies CMS requirements while maintaining clinical relevance 2.
Key Documentation Pitfalls to Avoid:
- Failing to document at least 10 systems will downcode your visit to a lower level, even if medical decision-making supports level 5 1
- Copying forward previous ROS without updating violates CMS documentation integrity requirements 1
- Using templates without personalizing to the patient's actual responses can be flagged during audits 1
Clinical Value Beyond Billing
The comprehensive review of systems has demonstrated therapeutic yield of approximately 7% in identifying unsuspected clinically important diagnoses requiring new therapeutic interventions in ambulatory patients 2. This makes it a valuable case-finding maneuver beyond its billing documentation purpose 2.