Gastroenterology Coding Alert

Don’t down code due to lack of complete documentation.

If your gastroenterologist is not completing all the pertinent documentation for the review of systems (ROS), you might be losing out on opportunities to report a higher level E/M – watch out for instances wherein your clinician might not be documenting negative responses.

The third element of an E/M service, after the chief complaint (CC) and the history of the present illness (HPI), is the ROS — this portion of the E/M service trips up many coders because often they must select a lower code simply because the provider inappropriately used the statement “all systems negative.”

Ensure you’re properly counting your provider’s ROS with this primer to guarantee you’re not overcoding or undercoding his E/M services.

Differentiate ROS Levels

“The review of systems is a subjective account of a patient’s current and or past experiences with illnesses and or injuries affecting any of the 14 applicable organ systems,” explains Nicole Orofino, CPC, owner of Innovative Coding Analysis in Allentown, Penn.

You’ll need to know the differences between the three ROS levels to determining the proper level of history and therefore, E/M code level:

Problem-pertinent: A problem-pertinent ROS occurs when the provider reviews a single system during the encounter, presumably the system directly related to the problem identified in the patient’s history of present illness (HPI). For a gastroenterology practice, for example, “pertinent” refers to the gastrointestinal system which means your gastroenterologist reviews at least one item within the GI system.

A problem-pertinent ROS supports a level two new patient E/M service (99202) or a level three established patient E/M service (99213).

Extended: When your gastroenterologist conducts an extended ROS, he should review a “limited” number of systems. According to Medicare (and most other payers), “limited” should be a total of two to nine systems including the GI system.

An extended ROS can support a level three new patient service (99203) or a level four established patient service (99214).

Complete: When your provider reviews 10 or more systems, he achieves a complete ROS. A complete ROS can support a level four or five new patient E/M (99204-99205) or a level five established patient visit (99215).

Learn the Systems You Will Be Counting

There are 14 systems your provider might review: constitutional; eyes; ear, nose, and throat (ENT); cardiovascular; respiratory; gastrointestinal; genitourinary, musculoskeletal; integumentary; neurological; psychiatric; endocrine; hematologic/ lymphatic; and allergic/immunologic, Orofino explains.

Example: A new patient presents with difficulties in swallowing coupled with abdominal pain. The patient is questioned on whether the abdominal pain is present only after the person intakes food or it is present even despite the person not consuming anything. Your gastroenterologist then proceeds on to the exam and makes a decision from that information. This represents a problem-pertinent ROS (the GI system).

In the same example, your provider may also ask about fever (constitutional), throat pain (ENT), chest pain (cardiovascular) and excessive thirst (endocrine), which may result in an extended ROS.

How it works: Your gastroenterologist must individually document the systems with positive or pertinent negative responses. For any remaining systems up to the required 10, he can make a notation that all other systems are negative. “Other” is the keyword. If you don’t see that sort of notation, the provider must then document at least 10 individual systems to be able to assign a complete ROS.

Tip: Remind your provider to document every system he reviews so you can count it in your coding. Your gastroenterologist might have the habit of only documenting positive findings, but you should make it clear that documenting negative findings is just as important for supporting the billable E/M level. If your provider doesn’t document the work, he won’t get credit for it. You’ll have no choice but to code a lower level visit if you can’t justify the ROS portion.

Determine Who Can Record the ROS

Your gastroenterologist does not necessarily need to record the ROS himself. “The ROS may be documented by the patient or auxiliary staff as long as the physician/NPP initials and dates patient populated forms and states they reviewed and/or agree with this documentation,” Orofino says.

Example: ROS can be done by a physician assistant (PA), nurse practitioner (NP), and a medical assistant (MA). You may even have the patient fill out an ROS questionnaire, which the doctor reviews and signs. Your providers can use a form like the one on page 20 to personally capture the ROS, or the patient may complete the form himself. Either way, have your provider reference the ROS in the dictation, and initial and date the form.

“I don’t feel that the doctor has to capture the ROS, but do feel that he needs to review it with the patient to determine the level of care,”  says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia. “It helps our doctors and nurse practitioners to have the patient fill out a questionnaire that addresses their problems when they come to an appointment to make sure that all problems are addressed during their encounter. I encourage this as a good way to make sure that ROS is documented completely.”

Important: Patient-completed ROS templates may be OK, but ask your physician to make his documentation specific to each patient. Also, be sure your provider documents that the ROS was reviewed with the patient by noting any additional pertinent information. Forms completed by the patient at the initial visit can be used again during subsequent established patient visits provided that the physician reviews the initial form, updates the form with any changes, and the initials and dates the form indicating his review.

Pointer: “When a practice is under audit by an insurance company and documentation for E/M codes is requested, the forms the patient filled out, including the ROS, should be included to gain credit for the ROS unless the physician takes the visit and dictates a comprehensive overview of what is contained in the chart,” Orofino explains.