Internal Medicine Coding Alert

Differentiate extended and complete systems review to judge if 99204 wins out over 99203.

If you fail to correctly assess the review of systems (ROS) your internist documents in the chart, you could be costing the practice valuable earned E/M time.

Check out these FAQs to identify which level ROS the encounter fits before choosing a level of history and, subsequently, an E/M code.

What Is ROS?

ROS is part of the history component of an E/M service; it 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, CPCH, coding specialist for Florida's Centra Care.

The ROS may be listed as separate elements of history, or they may be included in the description of the history of the present illness (HPI). Ancillary staff or the patient (via a form) may  complete the ROS, but the physician must make a notation in the chart supplementing or confirming the information recorded by others, states the 1995 Documentation Guidelines for Evaluation and Management Services (www.cms.gov/MLNProducts/Downloads/1995dg.pdf).

According to CPT 2010, a system review includes the following elements:

›› constitutional symptoms (fever, weight loss, etc.)

›› eyes

›› ears, nose, mouth, throat

›› cardiovascular

›› respiratory

›› gastrointestinal

›› genitourinary

›› musculoskeletal

›› integumentary (skin and/or breast)

›› neurological

›› psychiatric

›› endocrine

›› hematologic/lymphatic

›› allergic/immunologic.

Level 1: Single ROS

For any one E/M service, the physician typically reviews at least one system, explains Kenny Engel, CPC, coding coordinator with Advanced Healthcare in Germantown, Wis.

When the physician reviews a single system, it is a problem-pertinent ROS. This ROS level can support up to a level-twonew 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, which pays $67.48 using the 2010 Medicare Physician Fee Schedule national rate) or a level-three established patient service (99213, ... an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity; $65.67).

Example: A patient presents with a chief complaint of "head cold and runny nose." The physician examines the patient's allergic/immunologic status and determines the cause is seasonal allergies, which qualifies as a single-system review.

Level 2: Extended ROS

Extended ROS, meaning the internist reviewed two to nine systems, can support up to a level-three new patient service (99203, ... a detailed history; a detailed examination; and medical decision-making of low complexity, which pays  $97.79) or level-four established patient service (99214, ... a detailed history; a detailed examination; medical decisionmaking of moderate complexity; $98.51).

Example: A chief complaint of "cold and cough" leads to a review of the patient's constitutional, allergic/immunologic, and respiratory systems.

Important: An extended ROS does not necessarily qualify an encounter for 99203 or 99214; although it does make reporting these codes possible. For instance, if the internist saw a new patient and documented an extended ROS, but did not also have an extended history of present illness (HPI, four or more elements or the status of three chronic conditions), you would only be able to bill a 99202, counsels F. Tessa Bartels, CPC, CEMC, reimbursement manager for Children's Hospital of Wisconsin in Milwaukee.

Good advice: "Of course, history is only one of the three key elements. Documentation of your exam and medical decision making would also have to support the chosen level of service," Bartels says.

Level 3: Complete ROS

For a complete ROS, most insurers accept a review of 10 or more systems, says Forde.

With a complete ROS, reporting a 99204 (... a comprehensive history; a comprehensive examination; medical decision making of moderate complexity; national Medicare rate: $151.56), 99205 (... a comprehensive history; a comprehensive examination; medical decision making of high complexity; $190.53), or 99215 (... a comprehensive history; a comprehensive examination; medical decision making of high complexity; $132.79) is possible -- depending on other encounter specifics, of course.

Example: The internist sees an elderly patient with multiple chronic conditions, such as chronic obstructive pulmonary disorder, congestive heart failure, hypertension, and diabetes. In this scenario, the internist may inquire about 10 or more of the systems, such as constitutional, eyes, cardiovascular, respiratory, integumentary, neurological, psychiatric, hematologic/lymphatic, gastrointestinal, and endocrine.

Documentation: The documentation that is considered proof of having performed the complete ROS varies by payer, notes Bartels. Some will allow a specific list of pertinent positive and negative systems plus an "all other systems negative" statement. Other payers want the systems individually named and listed. Some may require a review of fourteen systems, while others will accept a complete ROS after the physician reviews 10 systems. The bottom line is check with the individual payer for guidelines before coding.

Keep in mind that "medical necessity drives the ROS train," and performing a complete ROS for a simple complaint to justify a higher E/M code is not appropriate, emphasizes Bruce Rappoport, MD, CPC, CHCC, a board-certified internist and medical director of Broward Health's Best Choice Plus and Total Claims Administration in Fort Lauderdale, Fla.

"The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported," states the Medicare Claims Processing Manual, Chapter 12, Section 30.6.1 (www2.cms.gov/manuals/downloads/clm104c12.pdf).