Medicare Compliance & Reimbursement

Tip: Thorough documentation helps determine the E/M level.

When choosing the correct E/M level for a patient visit, you may not look too closely at your review of systems (ROS) — but this element can make all the difference between codes. To ensure that you understand the ROS nuts and bolts, take the following quiz and find out if you know how to answer these common questions.

Question 1: Why Is An ROS Needed?

Answer 1: “From a medical perspective, a review of systems is needed to better understand the current condition of the patient,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director compliance audit at Cancer Treatment Centers of America. “If a patient arrives with problem X, and has an unrelated problem Y, the treatment options for X might be limited based on the Y,” Hauptman further explains.

More formally, as CPT^® guidelines put it, the ROS “helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options.”

As a coder, however, you know that the ROS plays a different role. “To guide a patient’s E/M, you need a reasonably thorough ROS,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. The extent of the review will, of course, be dependent on the chief complaint and presenting problems.

Question 2: What Are the ROS Levels, And How Do They Contribute to Code Choice?

Answer 2: CPT^® identifies 14 different systems (constitutional symptoms [e.g., fever, weight loss, etc.]; eyes; ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic) in total.

CPT^® also provides three different levels of review: a problem-pertinent review (one system); an extended review (two through nine systems); and a complete review (10 or more systems).

These different review levels help determine the extent of the history you will need to justify the different E/M levels. The lowest level of E/M, 99201/99212 (Office or other outpatient visit for the evaluation and management of a new/established patient …) needs no system review. The next level, 99202/99213, requires an expanded problem-focused history as one of the three components needed for a new patient E/M service or one out of the two possible components needed for an established patient. This requires a problem-pertinent ROS.

To justify a level of 99203/99214, you’ll have to document an extended review, which will help you support a detailed history as one of the E/M components. For the very highest level (99204-5/99215), you will need a complete ROS, which you will need to justify a comprehensive history, one of the three components required to justify a level-four or five new patient visit, and one of the two possible components necessary for a level-five established patient visit.

Question 3: How Should You Document the ROS?

Answer 3: Simply put, “it is important to have evidence that the review took place,” Hauptman says.

This means documenting “both positive and negative findings for any pertinent system,” Falbo offers as a reminder. So for example, a review of the gastrointestinal system for a patient complaining of breathing issues could include notes about negatives, such as “No complaints of nausea, vomiting, or change in stool pattern, consistency, or color,” as well as positives such as “Burning epigastric pain at night, approximately twice a month,” Falbo adds.

The review can also include systems that are not directly related to the problems identified in the history of present illness (HPI). In the above example of the patient complaining of breathing issues, you could count a review of the ears, nose, mouth, and throat if the provider documented that the patient had no complaints of headache, change in vision, or problems with the nose or ears.

But it is important that ROS documentation sticks with elements related to a system and not to the patient’s past medical history. For example, “if the provider documents, ‘No known drug allergies,’ this is past medical history and not ROS. To count as ROS, the provider would need to document something like, ‘no wheezing,’ which would count as a review of the respiratory system,” Falbo concludes.