ED Coding and Reimbursement Alert

Question: Can we use nurses' notes to satisfy elements of ROS and PFSH, as long as the physician documents his review of the notes?

Minnesota Subscriber Answer: As long as the physician signs the nurse's notes and documents that he reviewed them, you can meet the requirements for review of systems (ROS) and past/family/social history (PFSH) with information from the nurse's notes. You'll use ROS and PFSH, along with the patient's history of present illness (HPI), to decide how much information the physician gathered about the patient's history.

The review of systems is basically an inventory of the body so the physician knows where to direct the physical examination. It may include evaluations of any of the following systems or parts: allergic/immunologic, cardiovascular, constitutional symptoms, ears/nose/mouth/throat, endocrine, eye, gastrointestinal, genitourinary, hematologic/lymph, integumentary, musculoskeletal, neurological, psychiatric, and respiratory.

For a problem-pertinent ROS, the physician needs to review a single system or part and will usually map to evaluation and management codes 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history, an expanded problem- focused examination, and medical decision-making of low complexity) or 99283 (... an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity).

If the physician reviews two to nine systems, you should consider the ROS "extended," which means it usually translates to 99284 (... a detailed history, a detailed examination, and medical decision-making of moderate complexity). If he looks at at least 10 systems, the ROS is "complete," which may earn a 99285 (... a comprehensive history, a comprehensive examination, and medical decision-making of high complexity).

A "pertinent" PFSH consists of any one element - information about a patient's past health history, family history, or social history - and earns a 99284. For a "complete" PFSH, the doctor must have information about two of these areas. The complete PFSH translates into 99285.