ED Coding and Reimbursement Alert

A lack of E/M coding smarts can cost your ED when it comes to determining review of systems (ROS) levels. In some instances, it can make all the difference when choosing an ED E/M service.

Got your sights set on precision ROS selection skills? Check out this FAQ to master all three ROS levels and become an ROS coding sure shot..

ROS is part of the history component of an E/M service. During ROS, the physician might review "systems directly related to the problem or problems identified in the HPI and a limited number of additional systems," explains Judy Newberry, LPN, CPC, CCS-P, medical coding director for Insurance-Data Services in Wyoming, Mich.

Example: A patient reports to the ED complaining of a headache. The physician asks the patient how long the headache has lasted, how frequently she gets headaches,and whether she is taking any medication for  the headache. With these questions, the ED physician just reviewed one system (neurological).

For any E/M service, the physician reviews at least one system. The number of additional systems the physician reviews depends on the nature of the presenting problem [NOPP], points out Kenny Engel, CPC, coding coordinator with Advanced Healthcare in Germantown, Wis.

According to CPT 2010, "the following elements of a system review have been identified:

• constitutional symptoms [fever, weight loss, etc.]

• eyes

• ears, nose, mouth, throat

• cardiovascular

• respiratory

• gastrointestinal

• genitourinary

• musculoskeletal

• integumentary [skin and/or breast]

• neurological

• psychiatric

• endocrine

• hematologic/lymphatic

• allergic/immunologic."

Best bet: When counting ROS, be sure to include each review question under one of these categories.

According to the CMS documentation rules, there are three different levels of ROS, and you must identify ROS level before choosing an E/M code.

When the physician reviews a single system, it is a problem-pertinent ROS. This level of ROS can only 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 ...).

When the physician reviews two to nine systems, it is an extended ROS, reports Newberry. This level supports up to a level-four ED E/M (99284, ... a detailed history; a detailed examination; and medical decision making of moderate complexity ...). (Note: This does not mean that all extended ROS encounters are 99284s; the extended ROS makes 99284 possible but does not guarantee it.)

For a complete ROS, most insurers accept a review of 10 or more systems, says Pat Chapman, RHIT, CCS, ER coder at Ketchikan General Hospital in Ketchikan, Alaska.

With a complete ROS, reporting 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components with the constraints imposed by the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; medical decision making of high complexity ...) is possible -- depending on other encounter specifics.

Careful: If you've got a CPT stickler for a payer,check its ROS requirements before coding.

"Per CPT nomenclature, a complete ROS would necessitate a review of all additional body systems. This would include 14 systems. However, the CMS Documentation Guidelines define a complete ROS as covering at least 10 organ systems," Engel explains.

Most payers are not so strict, however, and will consider it a complete ROS after the physician reviews 10 systems.