Gastroenterology Coding Alert

Question: Encounter notes indicate that during the course of an E/M, a patient complains of stomach pain. In response, the physician asks the patient to describe the location and severity of the pain; he also asks the patient if he has had any diarrhea, flatulence, or gastroesophageal reflux. Is this a problem-pertinent or extended review of systems (ROS)?

South Carolina Subscriber

Answer: This is a problem-pertinent ROS, in which the physician conducts a single system review directly related to the problem(s) identified in the history of present illness (HPI).

A problem-pertinent ROS can support up to a level-two new-patient E/M (99202, Office or other outpatient visit for the evaluation and management ...) or a level-three established-patient E/M (99213).

To reach the next level of ROS (extended), the physician must review between two and nine systems. Although your physician did ask about four issues (stomach pain, diarrhea, flatulence, reflux), all the questions were part of a gastrointestinal system review.

-- Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.