Neurology & Pain Management Coding Alert

These FAQs answer your top recording and amount dilemmas.

Ever heard a chart doesnt have enough ROS to support a certain office visit level and wondered where the numbers come from? End the mystery with this element primer.

What Is an ROS?

A Review of Systems (ROS) is the subjective portion of a patients visit. The physician asks questions to help identify signs and/or symptoms that the patient may be experiencing or has experienced.

The ROS is basically an inventory of the body systems so the physician knows where to direct the physical examination, says Susan Vogelberger, CPC, CPC-H, business office coordinator in Beeghly Medical Park in Ohio.

Who Can Obtain the Responses?

An ROS is obtained in several ways. The patient could complete a healthcare assessment form while waiting to be seen, says Suzan Hvizdash, CPC, CEMC, CEDC. The person that rooms the patient could ask a series of questions that are then reviewed by your neurologist. Also, the provider could ask the series of questions and record the answer given directly into his/her note, Hvizdash adds.

What Systems Might You See?

Medicare defines neurologic as one of the systems that should be documented during an ROS. Examples of a neurological ROS might include symptoms such as numbness, tingling, headaches, dizziness, involuntary movements, and seizures, Hvizdash says.

 Your neurologist must document the patients positive and pertinent negative responses. Depending on the problem the patient presents, the systems reviewed and possible elements could include:

 " Constitutional: Fevers, chills, weight loss or gain, etc.
 " Gastrointestinal: Nausea, vomiting, abdominal pain, bowel movement routine, etc.
 " Genitourinary: Nocturia, frequency, pain, etc.
 " Cardiovascular: Chest pain, palpitations, syncope, edema, etc.
 " Respiratory: Shortness of breath, sleep apnea, etc.
 " Eye: Glasses, double or blurred vision, cataracts, etc.
 " ENT: Ringing in ears, infections, nasal congestion, etc.
 " Psychiatric: Mood changes, depression, affect, insomnia, etc.
 " Skin: Rashes, hives, discolorations, etc.
 " Musculoskeletal: Joint pain, muscle pain or cramping, stiffness, etc.
 " Integumentary: Growth or loss of hair, itching, rashes, etc.
 " Endocrine: Excessive sweating, excessive hunger or thirst, etc.
 " Hematologic/Lymphatic: Bleeding problems, bruising, anemia, etc.
 " Allergic/Immunologic: Immune problems, allergy reactions, etc.

Whats the Difference Between ROS Types?

A problem-pertinent ROS inquires about the system directly related to the patients chief complaint.  It is one element of an expanded problem focused history, which can support up to a level-two new patient E/M (99202, Office or other outpatient visit for the evaluation and management of a new patient ...) or go toward a level-three established patient E/M (99213, & an expanded problem focused history; an expanded problem focused examination; medic-al decision making of low complexity ... ) An example of a neurologic problem-pertinent ROS might be:

New patient presents with headaches. The patient is questioned on dizziness (780.4) or seizures (780.39) associated either before, during, or following the headache. Your neurologist moves on to the exam and makes a decision from that information.

An extended ROS inquires about the system directly related to the problem(s) identified in the history of present illness (HPI) and a limited number of additional systems. Your neurologist should document the patients positive responses and pertinent negatives for two to nine systems for this level.

An extended ROS is one component of a detailed history, which can support up to a level-three new patient E/M (99203, ... a detailed history; a detailed examination; medical decision making of low complexity ...) or be part of a level-four established patient E/M (99214, ... a detailed history; a detailed examination; medical decision making of moderate complexity ...) In the above example of headaches, your provider may also ask about neck pain (musculoskeletal), blurred vision (eyes), and insomnia (psychiatric), which may result in an extended ROS.

A complete ROS is necessary for a comprehensive history. The physician must review 10 or more systems or some systems with a statement indicating all others negative. Codes 99204 and 99205 require a comprehensive history; it may be one of the two key components necessary for 99215.

Caution: ROS level alone is not responsible for code assignment. The HPI; patients past, medical, family, and social history; the extent of the physical exam performed; and the complexity of medical decision making all con-tribute to the correct E/M code. Alternatively, the amount of time your physician spends counseling the patient may be the controlling factor in determining the visits level.