ED Coding and Reimbursement Alert

Understand how ROS ties into your overall E/M charges.

If you’re not able to correctly assess the review of systems (ROS) your physician documents, you could be costing your ED practice valuable reimbursement. And because all but the lowest of ED E/M levels require you to document ROS, the lack of one could slash your pay significantly if you fail to include it in your charts.

Check out the following frequently-asked questions about calculating the ROS level, and understand how you can use this E/M element to your advantage.

Question 1: Which Elements Are Included in the ROS?

Answer 1: During the ROS, the provider asks the patient questions about symptoms they may be experiencing. It’s part of the history, done to make sure nothing important has been missed. Providers perform ROS to focus treatment options and rule out any potential problems that they did not spot in the history of present illness (HPI) portion of the encounter.

• Constitutional
• Eyes
• Ears, Nose, Mouth, Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunologic

The ROS assists physicians when they are narrowing down a diagnosis, and it usually focuses on the patient’s signs and symptoms. For example, suppose a patient reports to the ED complaining of a severe headache. The headache is a symptom, but the physician seeks to determine what could be causing it. It could be muscle tension, a hangover, an aneurysm, migraine, etc. By asking ROS questions, physicians get a better idea of the cause of the patient’s presenting problem.

Question 2: Which ROS Levels Apply to E/M Services?

Answer 2: There are three levels of ROS. The first level is problem-pertinent, which occurs when the physician reviews only the system related to the patient’s problem.

Depending on the other encounter specifics, a problem-pertinent ROS can support up to a level-three E/M (99283, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of moderate complexity ...). Medicare reimburses about $73 for this code.

Here are some examples of problem-pertinent ROS:

• “Patient has a headache, and the physician asks about blurred vision.” (Eyes)
• “Patient has chest pain, and the physician asks about palpitations.” (Cardiovascular)
• “Patient has shortness of breath, and the physician asks if she experiences any coughing or painful respiration.” (Respiratory)

When the ED physician reviews between two and nine systems during an E/M, they’ve performed an extended ROS, which means that even a single comment about two separate systems would qualify as an extended ROS.

These reviews result in detailed histories and, depending on encounter specifics, can support up to a level-four ED E/M (99284 … a detailed history; a detailed examination; and medical decision making of moderate complexity ...). This code pays approximately $124, according to the Medicare Physician Fee Schedule.

Example: A patient presents complaining of chest pain. The physician asks the patient about the frequency of the pain, and whether she has palpitations. The doctor then asks the patient if she is experiencing shortness of breath or nausea. In this example, the physician reviewed three systems (cardiovascular, respiratory, gastrointestinal), so this is an extended ROS.

The third level is a complete ROS, in which case the physician must review at least 10 systems or, per the 1995 Documentation Guidelines, document a statement of “all others reviewed and negative” after documenting those systems with pertinent negative or positive responses.