General Surgery Coding Alert

Question: When coding E/M services, can we count the same element twice, for instance, as a component of both the history and review of systems (ROS), even if the doctor doesn't note it in two separate locations?

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Answer: As long as the physician documents the item clearly, you can count it in both areas.

A top CMS official, Executive Medical Officer Barton McCann, said so in a famous 1998 letter to Mason Smith with Lynx Medical Systems in Bellevue, Wash.

-It is not necessary to mention an item of history twice in order to meet the Documentation Guidelines requirement for the ROS,- McCann wrote. -It is important that the information which is provided can be inferred accurately and appropriately by a reviewer to determine level of service and medical necessity.-

E/M documentation guidelines are supposed to help you find the correct level of service and -not to be perceived as a burden to the physician,- McCann said.

Example: A patient presents with several problems, including chest pain with dyspnea.

You can count chest pain and dyspnea as location and associated signs and symptoms in the history, as well as the respiratory section of the ROS.

Warning: If the patient shows up with only one complaint, however, you shouldn't use that single complaint for both ROS and history. After all, the form wouldn't have a space for -none taken- under ROS if you could just take any element from the history and use it for ROS.

Instead, you need to have evidence the physician dug deeper. So including just -abdominal pain- in the history and ROS, for instance, is probably a bad idea, especially if that's the only complaint. But including -abdominal pain, no nausea- in ROS is acceptable because that shows the doctor asked additional questions of the patient.

Important: You shouldn't use the same statement twice within history or within review of systems.

Bottom line: You should get out of the mindset of -looking for words or phrases- to stick into boxes. Physicians don't always put E/M documentation in the correct area on the visit notes, and the heading doesn't always tell you where it belongs. For instance, you might find -review of systems- information in the exam section of the note because sometimes the physician will ask questions while he examines the patient.