EM Coding Alert

Find the right level for all your ED E/M encounters.

Maybe your review of systems (ROS) knowledge is a little rusty. Maybe you’re new to the ED E/M game. Whatever your current level of understanding, answering these three basic questions will give your history levelling skills a major boost.

Read on and see how well you perform on this ROS refresher.

Question 1: How do we determine which elements are included in the ROS?

Answer 1: During the ROS, the provider asks the patient questions about symptoms he 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.

During the ROS, the physician is trying to learn as much as possible about what other problems a patient has that might affect how he will treat the patient. For coding purposes, CPT^® breaks the body into these systems:

• 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, a patient reports to the ED complaining of a headache. The headache is a symptom, but the physician seeks to determine what could be causing the headache. It could be muscle tension, a hangover, an aneurysm, 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 ...).

Here are some examples of a 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, she has 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 ...).

Example:  A patient presents complaining of chest pain. The physician asks her about the frequency of the pain, and whether she has palpitations. He 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.

Example: “Patient denies fever, blurred vision, sore throat, chest pain, shortness of breath, nausea or vomiting, swollen joints, rash, headaches, or swollen glands.”

This note is acceptable documentation for a complete ROS, as it proves the physician inquired directly about the following systems: Constitutional; eyes; ear, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; musculoskeletal; integumentary; neurologic; and lymphatic.

Question 3: Which questions are valid to ask the patient to determine the ROS?

Answer 3: The ED physician should ask pointed questions when conducting the ROS.

Best-practice ROS question: “Have you had any recent feelings of hopelessness, anxiety, or irrational fear?”

Less helpful ROS Question: “Any psychiatric issues I should know about?”

The physician should ask directly about each system. Even if the findings for those systems are negative, you can still count them toward a total ROS.

Example: “Admitted for chest pain, patient reports to difficulty breathing, diaphoresis, and nausea, but a complete ROS is otherwise negative.” Provided the physician asks the patient direct questions about each negative system, this also satisfies requirements for a complete ROS.