Internal Medicine Coding Alert

Question: A 66-year-old new Medicare patient reports to the practice complaining of stomach pain. In response, the nonphysician practitioner (NPP) asks the patient to describe the location and severity of the pain; he also asks the patient if he has suffered any diarrhea, flatulence, gastroesophageal reflux, or vomiting along with the pain. The patient reports that the pain is a 7 on a scale of 10, and reports that he has vomited and had diarrhea during the past two days. Is this a problempertinent or extended review of systems (ROS)?

California Subscriber

Answer: The NPP conducted a problem-pertinent ROS, as he (thoroughly) reviewed a single system directly related to the problem(s) identified in the history of present illness (HPI).

A problem-pertinent ROS can support up to a leveltwo new patient E/M (99202, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision-making ...)

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

A complete system review requires 10 or more system reviews.

Further, since this was a new patient, you should not report the NPP's services incident-to the physician. You must code under the NPP's National Provider Identifier (NPI) for this encounter.