ED Coding and Reimbursement Alert

WPS Medicare changes ROS documentation requirement, only to reverse its decision

The end of 2006 featured a decision by a major Medicare carrier concerning documentation on review of systems (ROS). In it, the carrier contended that documentation for a complete ROS should be more detailed than Medicare requires in its 1995 or 1997 documentation guidelines (DGs).

However, after causing a brief panic in the coding community, the carrier refined its statement, putting its documentation requirements back in line with the 1995 DGs.

-This issue has continued to evolve,- says Michael A. Granovsky, MD, CPC, FACEP, president of Medical Reimbursement Systems Inc., an ED coding and billing company in Woburn, Mass. And in fact, many think the ROS documentation debate may not be over, as other carriers could continue to press for more detailed ROS on evaluation and management claims in the future.

Here's the lowdown on the ROS issue, and some advice on documenting ROS on your claims:

WPS Reverses Ban on -All Other Systems Negative- Reporting

In mid-November, WPS Medicare, the carrier for Wisconsin, Illinois, Michigan and Minnesota, issued the following statement: -For a complete ROS, the examiner inquires about the system(s) directly related to the problem(s) identified in the history of present illness (HPI), plus all additional body systems. At least 10 organ systems must be reviewed. Due to a recent clarification from CMS, those systems addressed in the ROS must be individually documented. All systems reviewed should be documented, regardless of findings. It is no longer appropriate to just state -all other systems are negative- without specifically listing those systems reviewed.-

The italicized sentence is what gave EDs pause, says Rebecca Parker, MD, FACEP, chair of ACEP's Coding and Nomenclature Advisory Committee, and president of Team Parker LLC, a coding, billing and compliance consulting firm in Lakewood, Ill.

According to the Medicare DGs, it was permissible to state -all other systems negative.- This puzzling edict from WPS caused concern in the coding community, because it seemed to contradict the DGs. -Some Medicare carriers have had variable preferences on how to document a complete ROS, but they conceptually defer to the CMS 1995 or 1997 DGs as the final authority,-   Parker says.

Shortly after issuing the statement, however, WPS changed its mind, Granovsky says.

Explanation: -WPS has now reclarified its position and states that it will follow the 1995 DGs,- Granovsky says. This means that when reporting a complete ROS on a claim, you should adhere to these 1995 DGs:

-At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating that all other systems are negative is permissible.-

Stay Abreast of Medicare Carriers- ROS Rules

The WPS clarification is a welcome return to old guidelines, but Granovsky says the issue may not be dead.

-This is an evolving area of compliance and documentation, so EDs should stay tuned as individual Medicare carriers may continue to initiate their own policies on ROS documentation,- he says.

So while WPS Medicare no longer requires documentation of each system the physician checks for a complete ROS, other payers may try to implement similar policies. 

Coders who don't want to get caught off-guard by ROS issues can take preemptive steps to ensure there are at least 10 organ systems documented on complete ROS claims, Parker says.

Try this: -For physicians and midlevel providers, I recommend that they construct their own 14-system checklist, whether on their documentation template or a sheet they use to dictate from. They should address the pertinent positives and negatives and be sure they address at least 10 systems,- Parker says. If you follow this checklist each and every time the physician performs ROS, then you-ll have solid documentation on each of your claims.

-I have a set of 10 systems I review with the patient after completing the HPI during my interviews and then document individually. This way I always remember to address and document at least 10 systems- for a complete ROS, Parker says.

(For information on ROS reporting, see -Observe 10-System Minimum for Complete ROS- in this issue.