ED Coding and Reimbursement Alert

Deciphering review of systems (ROS) documentation challenges coders who struggle with the differences between ROS, the history of present illness (HPI), and the physician exam elements involved with choosing an E/M level for ED codes (99281-99285).

Coders most assuredly know that E/M levels are based on three components: history, physical exam, and medical-decision-making. Their real challenge stems from the fact that the systems referenced in the ROS portion of the E/M history component also fall under the physical exam portion of the patient encounter. For example, respiratory is recognized as a body system in the ROS. It is also considered an organ system under the elements of exam. So, several statements included in a patients chart can refer to breath. This raises a host of questions. What elements of the documentation should statements about the patients breathing support? Should they support the ROS or the exam? And what should coders do if there is an overlap between the ROS and the HPI?

Coders should remember that documentation does not have to state specifically whether the item is an ROS. Anything that meets the requirement for a system review can be counted regardless of its location in the chart, says Todd Thomas, CPC, CCS-P, president, Thomas & Associates, a reimbursement consulting firm for emergency physicians in Oklahoma City.

Think of the ROS process as an interview in which the doctor or nurse asks the patient about an organ system and the patient responds. The information could also come from a questionnaire the patient completes. In short, the responses should be, and consequently look like, statements the patient would make.

For example, if the nurse documents breath sounds normal or breath sounds bilateral, he or she obviously examined the patient to get that information, Thomas explains. An exam response or one that has a medical standard element would fall under the exam rather than the ROS. A more likely ROS statement would be difficulty breathing, if the patient has a respiratory problem or respiratory negative, if the patient has no difficulty breathing.

Keep in mind that ROS documentation is active, that is, it describes a patient having problems with a particular body system at the time of the encounter. You would not find a statement that contains no history of or history of in an ROS. It would be part of the HPI. For example, no history of asthma or no history of cardiac problems would be elements of HPI or PFSH (past, family, social history).

Be Careful With Blanket ROS Statements

Blanket statements such as doing well and all systems negative add to the coders challenge.

The all systems negative statement is an inaccurate description of a patient with a complaint, Thomas adds. What we look for in the chart is all other systems negative. Other is the key word. Documentation guidelines indicate that documenting pertinent positives and negatives combined with the statement all other systems negative can be considered a complete review of systems.

Most templates ED physicians use have an option to mark all other systems negative or all systems negative other than marked or indicated as a part of the ROS.
However, checking that box or providing a dictated statement to that effect is not enough to determine whether the item can be categorized as part of an ROS.

Usually the ROS as a whole cannot be negative; however, physicians occasionally see patients without problems in their body systems. For example, an ED physician examines a child involved in a minor car accident. The child is free from pain or obvious injuries, with no identifiable signs or symptoms. But the physician still performs an ROS to rule out possible injuries. The physician will ask, Are you having trouble breathing? Can you move your arms and legs? Hands and feet? Thomas says. These are ROS components. Because there are no problems, each response should be stated as negative. Then the physician would also write in the patients chart all other systems negative.

Use the Level-five Caveat When You Need It

Coders can use an existing documentation exception when a patient is unconscious or the ED physician and staff must work so quickly to save a life that performing an ROS would endanger the patient. The level-five caveat (within the constraints imposed by the patients clinical condition and/or mental status) precludes an ROS if the patient is uncooperative, unconscious or in danger of losing his or her life. CPT and HCFA endorse this acuity exception only if documentation supports it.

Its also important that the documentation be crystal clear. Sometimes the waters are muddied. For example, an ED physician documents the inability to perform an ROS because the patient is unconscious and then proceeds to document elements of an ROS. This is a red flag to payers. Its confusing to look at a chart and read, unable to obtain history and then see historical information in that very chart, Thomas says. Many times, this type of information comes from the patients family, nursing-home staff or EMS. So, if you get history from any other sources, be sure to indicate what they are.

To qualify for the exception, HCFA, as well as many other payers, would like to see in the documentation reasons the ROS was not possible: The patient was too ill, uncooperative, unconscious, or the staff had to act quickly, he explains. And this documentation also must state how the history was taken and where the information came from.

ROS Significant in Determining E/M Level

The extent of the ROS is a key factor in determining which level to code an E/M service. A chart that lacks documentation of an ROS rates only a level-one code (99281). If two to nine systems are documented, the level can range from a two (99282) to a four (99284).

In order to reach the level five (99285) the physician must document a complete ROS (10 systems related to the presenting problem in HPI). Performing an ROS is ingrained in a physicians mind, Thomas states. Physicians almost always perform an ROS during an ED encounter. The problem is they might not document it. Penny Lodes, PN, CPC, president of Lodes and Associates, coding consultants in Appleton, Wis., offers a reason. Quite often physicians forget to document some of the systems because they are negative, she says, but, if they dont document their work, they dont get credit for it.

Many physicians document only positive findings, particularly elements that affect the encounter or the diagnosis and treatment. However, documenting negative findings is just as important for supporting the billable E/M level. As a coder, it is very frustrating to go through a nice, well-documented chart and only have nine ROS. Youll have no choice but to code it as a level-four visit unless you can justify using the acuity caveat, Thomas says.

Note: According to AMA CPT 2001 E/M Services Guidelines, body systems recognized for ROS are constitutional systems (fever, weight loss, etc.); eyes; ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointenstinal; genitourinary; musculoskeletal; integumentary (skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic.