Cardiology Coding Alert

Do you know what it takes for ROS to be 'complete'?

If you want to capture the highest level consultation codes (99244-99245 and 99254-99255), then you've got to be certain you have your review of systems (ROS) documentation in line. Review this basic information, and you could be upping your cardiology practice's reimbursement.

Brush Up the Basics

The basics: "An ROS is a set of questions the physician asks that inquire about each system of the body. The main purpose of the ROS is to be sure no important symptoms have been missed, especially in areas not already covered in the history of present illness (HPI)," says Rebecca Parker, MD, FACEP, chair of the American College of Emergency Physician's Coding and Nomenclature Advisory Committee, and president of Team Parker LLC, a coding, billing and compliance consulting firm in Lakewood, Ill.

In other words, the ROS is a body system inventory so the physician becomes acquainted with patient history and knows where to direct the physical examination. The inventory may include evaluations of any of the following organ systems: allergic/immunologic, cardiovascular, constitutional, ears/nose/mouth/throat, endocrine, eye, gastrointestinal, genitourinary, hematologic/lymph, integumentary, musculoskeletal, neurological, psychiatric and respiratory. The ROS alone does not determine the service level, but if your cardiologist does not document any ROS, then you cannot report anything higher than the lowest possible consultation level (99241 or 99251), assuming the service is consultative.

Here's your breakdown for the history key element:

• Problem-Focused: a chief complaint, 1-3 history of present illness (HPI) elements or the status of 1-2 chronic/inactive conditions. (Correlates with 99241/99251, inpatient consultation and outpatient consultation, respectively.)

• Expanded Problem-Focused: a chief complaint, 1-3 HPI elements or the status of 1-2 chronic/inactive conditions, and one review of systems element. (Correlates with 99242/99252.)

• Detailed: a chief complaint, 4 HPI elements or the status of 3 chronic/inactive conditions, 2-9 review of systems elements, and one of the medical, family, or social histories. (Correlates with 99243/99253.)

• Comprehensive: a chief complaint, 4 HPI elements or the status of 3 chronic/inactive conditions, 10 review of systems elements or the documentation of positives, pertinent negatives, and the statement "all others negative," and all three of the medical, family, and social histories. (Correlates with 99244-99245 and 99254-99255.) Watch out: TrailBlazer (Medicare carrier for Delaware, District of Columbia, Maryland, Texas and Virginia) does not permit the "all others negative" shortcut. TrailBlazer expects providers to always identify which systems the cardiologist queried and found to be "negative." 

In other words, if all your cardiologist documents is 2-9 review of systems elements, the highest level of consultation the documentaion supports will be level three (99253/99243).

ROS Isn't Everything

The level of your history will help you decide your level of consultation, but remember that the final service level will also depend on the levels of exam and medical decision-making, says Melanie Witt, RN, CPC-OGS, MA, a coding expert based out of Gaudalupita, N.M. "The lowest of the three key components will direct you to your code."

In other words: If the cardiologist did not document anything above a problem-focused history, despite moderate medical decision-making and a comprehensive physical exam, you are looking at only a low level (99241/99251) consultation code. And as you can see, doing or not doing the ROS is important to getting a higher history level, Witt says.