Medicare Compliance & Reimbursement

Observe 10-system minimum for complete ROS.

When a physician performs an evaluation and management (E/M) service, he conducts a review of systems (ROS) to check on the condition of the patient's body systems. If coders do not know the level of ROS the physician performs, they will be unable to decide which level of E/M code they should use on the claim.

The basics: "An ROS is a set of questions the physician asks that inquire about each system of the body. The main purpose of the ROS is to be sure no important symptoms have been missed, especially in areas not already covered in the history of present illness (HPI)," says Rebecca Parker, MD, FACEP, chair of ACEP's Coding and Nomenclature Advisory Committee, and president of Team Parker LLC, a coding, billing and compliance consulting firm in Lakewood, IL.
 
The ROS is essentially an interview in which the physician or nurse asks the patient about a specific system and records the patient's answers. Some physicians also get ROS information from patients via a questionnaire.

"CMS specifically defines 14 systems for documentation purposes," Parker says. Those systems are:

• constitutional symptoms

• eyes

• ears, nose, mouth and throat

• cardiovascular

• respiratory

• gastrointestinal

• genitourinary

• musculoskeletal

• integumentary (skin and/or breasts)

• neurologic

• psychiatric

• endocrine

• hematologic/lymphatic

• allergic/immunologic.

There are three levels of ROS: problem-pertinent, extended and complete. The level of ROS will determine your E/M code choice, so you need to know the requirements for each type of ROS the physician may perform.

Choose Problem-Pertinent For Minimal System Checks

If the physician performs a problem-pertinent ROS, it means that he reviewed one system for the patient during the E/M. A problem-pertinent ROS will support up to a level three. Consider this example:

A patient is vacationing and presents for suture removal from an uncomplicated wound that was repaired in his hometown ED. The chart simply states, "No complaints of wound redness" for the ROS.

On the claim, you should report 99281 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a problem-focused history; a problem-focused examination; and straightforward medical decision- making) for the service.

Tread Carefully When Choosing E/M Level For Extended ROS

If you are coding for an extended ROS, the physician has to document that she "inquired about the system directly related to the patient's problem and a limited number of additional systems," says Michael A. Granovsky, MD, CPC, FACEP, president of Medical Reimbursement Systems Inc., an ED coding and billing company in Woburn, MA.

According to Medicare guidelines, "the patient's positive responses and pertinent negative responses for two to nine systems should be documented." An extended ROS will support up to a level-four service, depending on the specifics of the encounter.

Consider this example from Parker:

A renal colic patient reports complaining of right flank pain with sharp, sudden onset. He says the pain radiates to the right lower quadrant with associated nausea and vomiting but no modifying factors. There is no fever or chills, and no hematuria noted. The patient also denies any rashes or any chest pain.

The physician orders IV fluids, IV pain medication with Toradol (a non-narcotic anti-inflammatory), a urinalysis, labs, and a KUB x-ray, which confirms the presence of a renal stone. After diagnosis and pain control, the physician sends the patient home with instructions to follow up with another physician.

In this instance, the physician performed an extended ROS including inquiries related to the following systems: gastrointestinal (nausea and vomiting), constitutional (fever or chills), genitourinary (hematuria), integumentary (rashes), and cardiovascular (chest pain).

On the claim, you should report 99284 (... a detailed history; a detailed examination; and medical decision- making of moderate complexity) for the E/M.
 
You Must Confirm 10+ Systems For Complete ROS

For a level-five ED visit, you must review at least 10 organ systems. The 1995 DGs allow a physician a documentation shortcut in the statement "All other systems are negative." However, this is not meant to be a substitute for performing the history, just a way to ease the documentation burden on the physician, Granovsky says. Complete ROS requirements are steep: the physician must document that he checked at least 10 systems for a complete ROS.

Consider this example from Parker:

A patient reports to the ED with left-sided dull chest pain that is radiating down the left arm. She also reports shortness of breath (respiratory) and nausea (gastrointestinal), which become worse when she ambulates.

The notes indicate that the patient has negative responses for fever (constitutional), eye discharge (eyes), rhinorrhea (ears/nose/mouth/throat), cough (respiratory), dysuria (genitourinary), headache (neurological), and rash (integumentary). The physician also notes that the patient reports some pain in her lower extremities (musculoskeletal) and has urinary frequency (genitourinary two). The physician orders an electrocardiogram (ECG), chest x-ray, labs, IV, aspirin, nitroglycerin and admit for chest pain to telemetry.

During this encounter, the physician checked a total of 10 systems (parenthetically noted above.) Remember, as in this example, a single system may only be counted once. Here genitourinary appears twice but only counts once as a system review. However, the session still satisfies the requirements for a complete ROS.

On the claim, you should report 99285 (... a comprehensive history; a comprehensive examination; and medical decision-making of high complexity) for the E/M.

Remember: Parker says that in cases in which the patient is unable to give a complete ROS (e.g., due to dementia, altered mental status, or the urgency of the condition), you may state "Unable to obtain a complete ROS secondary to condition ______" and count it as a complete ROS.

So if a patient arrives with severe dementia, you could report "Unable to obtain a complete ROS secondary to dementia" and still satisfy the payer's requirements for a complete ROS.

However, if you are unable to obtain a complete ROS due to a language barrier, you cannot claim complete ROS on the claim, Parker says.