Gastroenterology Coding Alert

A lack of E/M coding smarts can cost your gastroenterology practice when it comes to determining review of systems (ROS) level. In some instances, it can make all the difference when choosing an E/M service.

Check out this FAQ to master all three ROS levels and become an ROS coding sure shot.

ROS is part of the history component of an E/M service. CPT defines it as "[a]n inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced."

During ROS, your gastroenterologist might review systems directly related to the problem or problems identified in the history of present illness (HPI) portion of the E/M and a number of additional systems. As CPT notes, the ROS "helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options."

ROS is "a review of body areas/systems that directly pertains to the patient's current status and well-being. It is done by physicians to help assist in defining/diagnosing the patient's complaints," explains Celia Forde, CPC, CPC-H, coding specialist for Florida's Centra Care.

Example: A patient reports to the gastroenterologist complaining of a stomachache. The gastroenterologist inquires about how long the stomachache has lasted, and asks a few other questions about the abdomen to rule out ulcers. After the questioning and an abdominal exam, he prescribes several over-the-counter options to deal with the condition and tells the patient to come back in for another exam if the stomachaches worsen or increase in frequency.

In this instance, the coder can only consider one system reviewed (gastrointestinal), since the gastroenterologist has apparently only inquired about the system directly related to the problem.

(For a list of the 14 CPT systems, see "Use This List for ROS Success" on page 13.)

For any E/M service, the physician typically reviews at least the one system related to the complaint or symptom. The number of additional systems the physician reviews depends on the nature of the presenting problem, explains Kenny Engel, CPC, coding coordinator with Advanced Healthcare in Germantown, Wis.

There are three levels of ROS defined by CPT, and these levels can affect E/M code choice, so you need to pay attention to how many systems the gastroenterologist reviews for each E/M.

According to both the 1995 and 1997 CMS documentation rules, there are three different levels of ROS, and you must identify ROS level before choosing a level of history and, subsequently, an E/M code.

When the physician reviews a single system, it is a problem-pertinent ROS. This ROS level can support up to a level-two new patient E/M (99202, Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision- making) or a level-three established patient service (99213, ... an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity).

When the physician reviews two to nine systems, the encounter is an extended ROS. Extended ROS can support up to a level-three new patient service (99203, ... a detailed history; a detailed examination; and medical decision-making of low complexity ...) or level-four established patient services (99214, ... a detailed history; a detailed examination; medical decision-making of moderate complexity ...).

Caveat: An extended ROS does not necessarily qualify an encounter for 99203 or 99214; though it does make reporting these codes possible.

Example: A 51-year-old established patient reports to the gastroenterologist with recent right upper quadrant pain. The pain radiates toward her epigastric area and right flank. She has no prior history of similar pains and denies nausea, vomiting, or diarrhea. She rarely has heartburn, but occasionally takes an over-the-counter antacid. She is generally very healthy, and there is no fever or weight loss.

The patient also denies any shortness of breath, chest pain, skin rash, or itching. There are no urinary symptoms. In this situation, the different systems the physician notes indicate five system reviews; this is an extended ROS:

• She is generally very healthy. There is no fever or weight loss [constitutional].

• She denies any shortness of breath [respiratory].

• She denies chest pain [cardiovascular].

• She denies skin rash or itching [integumentary].

• She denies urinary symptoms [genitourinary].

For a complete ROS, most insurers accept a review of 10 or more systems, says Forde. The gastroenterologist must individually document those systems with positive or pertinent negative responses. For the remaining systems, a notation indicating all other systems are negative is permissible. Absent such a notation, the gastroenterologist must individually document at least 10 systems. With a complete ROS, reporting a 99204 (... a comprehensive history; a comprehensive examination; medical decision making of moderate complexity ...), 99205 (... a comprehensive history; a comprehensive examination; medical decision making of high complexity ...), or 99215 (... a comprehensive history; a comprehensive examination; medical decision making of high complexity ...) is possible -- depending on other aspects of the visit and documentation of the specifics.