General Surgery Coding Alert

Check for documentation of each system -- or prepare to assign a lower code.

Your surgery practice might see lots of level-four and -five office visits, but if you incorrectly tally the history, exam, and medical decision-making (MDM), you will miss out on the pay you deserve for higher level codes.

The third element for the historical portion of an E/M service, after the chief complaint (CC) and the history of the present illness (HPI), is the review of systems (ROS). This portion of the E/M service trips up many coders because the provider may not document pertinent negative responses, or may inappropriately use the statement "all systems negative." Use the following ROS primer to guarantee you're not overcoding or undercoding your surgeon's 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 Martin, CPC, manager of the medical practice management section of the Medical Society in New Jersey in Lawrenceville. 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 surgeon 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).

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 the physician 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.

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

Complete: When your surgeon reviews all 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

Physicians have 14 systems they might review: constitutional; eyes; ear, nose, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary; neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic, Martin explains.

Example: A newly referred patient presents with a potential hiatal hernia. The surgeon questions the patient about the abdominal bulge near the diaphragm (musculoskeletal), as well as asking about fever (constitutional), difficulty breathing (respiratory), and esophageal reflux symptoms (gastrointestinal).

Solution: This represents an extended ROS because the surgeon reviews four systems.

Tip: Remind your surgeon to document every system he reviews so you can count it in your coding. Many physicians document only positive findings, but documenting negative findings is just as important for supporting the billable E/M level. If your surgeon 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

The surgeon 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," Martin says.

Example: ROS can be done by a physician assistant (PA), nurse practitioner (NP), and sometimes a medical assistant (MA). You may even have the patient fill out an ROS questionnaire, which the doctor reviews and signs.

"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 address during their encounter," says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia,. "I encourage this as a good way to make sure that ROS is documented completely."