ED Coding and Reimbursement Alert

Question: Encounter notes indicate a patient presented to the ED following a collapse and blackout; the patient had reported having chest pain 5 minutes before the blackout. During the review of systems (ROS), the physician gets positive responses when she asks the patient about head pain, dizziness, chest pain, muscle pain, and breathing trouble. The patient also had several nicks and cuts incurred from the fall that the physician asked about. Then, the physician wrote "Review of all other systems negative." Does this qualify for a complete ROS?

Missouri Subscriber

Answer: You should be able to report a complete ROS -- though you are best served to include more specific documentation about the positive ROS checks.

Do this: Make sure that you have proof of the patient's positive ROS responses in the documentation:

• neurologic (head pain, dizziness)
• cardiovascular (chest pain)
• musculoskeletal (muscle pain)
• integumentary (cuts and bruises)
• respiratory (breathing trouble).

And then: You can use the "all other systems negative" quote or check box for the rest of the claim, but remember that is a documentation exemption rather than a performance exemption. Making such a statement without actually performing a complete review of systems would be inappropriate.

Payoff: Though the exact E/M level is not determined solely by ROS, a complete ROS can support up to a level-five ED E/M service (99285, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...).