Gastroenterology Coding Alert

Question: A new patient reports to the gastroenterologist with heartburn, stomach ache, and nausea. She also reports a chronic cough and trouble swallowing. The physician's notes indicate that the patient does not have a fever, eye discharge, dysuria, headache, or a rash. The physician also notes that the patient reports anxiety, some pain in her right shoulder, and has urinary frequency. How should I code for this visit and does it meet the ROS requirement?

Alabama Subscriber

Answer: This encounter does meet the review of system (ROS) requirement since the physician checked and documented a total of 10 systems as follows:

heartburn, stomach ache, nausea (gastrointestinal)

chronic cough (respiratory)

trouble swallowing (ear, nose, mouth, throat)

fever (constitutional)

eye discharge (eyes)

dysuria, urinary frequency (genitourinary)

headache (neurological)

rash (integumentary)

anxiety (psychiatric)

shoulder pain (musculoskeletal).

Tip: Remember, you can only count a single system once. Even though gastrointestinal and genitourinary systems were mentioned more than once, they only count once each. If the documentation does not specifically mention findings for 10 systems but the physician's note includes a statement that "all other systems were negative" then it can qualify as a Complete ROS.

On the claim, if documentation meets all other factors (history and exam), you would report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; a comprehensive examination; medical decision making of moderate complexity ...) or even 99205 (... medical decision making of high complexity ...) for the E/M.