Oncology & Hematology Coding Alert

Focus on problem-related ROS and keep a count of all systems examined.

Oncology review necessitates examination of more than one organ systems. When you’re coding for your provider’s E/M services, keep a close eye on the number of systems reviewed. If you don’t choose the proper review of systems (ROS) level, you will be hit hard by consequences of losing payment. Here’s some expert insight into choosing the right ROS level for every encounter.

Differentiate Limited and Complete ROS

“Based upon systems reviewed, the CMS 1995 Documentation Guidelines for Evaluation and Management Services divides the ROS into three different categories,” says Janae Ballard, CPC, COC, CPMA, CEMC, Manager, Professional Audit Services, Altegra Health, Los Angeles, CA. The three categories are as follows:

• A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI.
• An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems.
• A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

 An extended ROS can support up to a level-three new patient code (99203, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity), which pays about $109 (3.04 non-facility relative value units [RVUs] times the 2016 Medicare Physician Fee Schedule conversion rate of 35.8043).

“If a comprehensive examination, medical decision making of high complexity was performed, missing all elements required of a complete ROS, can be the ‘swing and a miss’ in being able to support the requirements for the highest level new patient visit,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Managing Director of Pinnacle Enterprise Risk Consulting Services (“PERCS”), a division of Pinnacle Healthcare Consulting. Remember, code 99205 (… a comprehensive history; a comprehensive examination; medical decision making of high complexity…) pays about $209 (5.82 non-facility RVUs times 35.8043). Don’t let deserved reimbursement fly out the door with skimpy ROS if it was reviewed with the patient and acknowledged in the billing provider’s note.

Know Your Systems Before Performing ROS Count

During an ROS, “the physician asks, or reviews, the patient’s body systems looking for any problems or symptoms the patient is experiencing,” explains Cathy Satkus, CPC, coder at Harvard Family Physicians in Tulsa, Ok.

For coding purposes, CPT^® considers each of the following body areas as systems:

• 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.

Once you are familiar with the different body systems, you’re ready to drill deeper into ROS with a primer on ROS levels.

Look For Problem-Pertinent ROS on Simpler Encounters

There are three levels you can choose from when scoring the review of systems (ROS): problem-pertinent, extended, and complete. When the provider performs a problem-pertinent ROS, she reviews and documents one (1) system during the encounter.

Depending on other encounter specifics, a problem-pertinent ROS can support up to a 99202 (… an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making…) for new patients, or a 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity…) for established patients.

Count at Least a Pair of Systems for Extended ROS

You’ll choose an extended ROS when the provider reviews between two (2) and nine (9) systems.

An extended ROS can support up to a level-three new patient E/M service (99203) or a level-four established patient E/M (99214, … a detailed history; a detailed examination; medical decision making of moderate complexity…).

Score each category of ROS: “A Pertinent ROS is defined as one (1) ROS related to the chief complaint. An Extended ROS is 2-9 positive and pertinent negative ROS related to the chief complaint. A complete ROS is at least ten (10) systems reviewed with the positive and pertinent negative systems documented,” Ballard says. “CMS will allow a statement of ‘All others are negative’ in addition to the positive and pertinent negatives to indicate other ROS were reviewed but were negative.”

Warning: You should not assume you can automatically code all extended ROS encounters with 99203 or 99214. The other elements of the encounter — the remaining history components (history of present illness and past medical, family, and social history), examination, and medical decision-making — must also satisfy the E/M requirements to justify your code choice.

Consider this example from Cynthia A. Swanson RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb.:

Example: A new patient presents to the oncologist for management recommendations after a new diagnosis of non-Hodgkin’s lymphoma. The patient generally has been feeling well other than his recent hearing loss (ears). He thinks he might be allergic to penicillin due to the rash he experienced the last time he took it (allergic/immunologic). There are traces of the rash, and he reports mild skin irritation (integumentary). His appetite and weight have been stable (constitutional). He denies headache (neurological) or visual symptoms (eyes). He notes occasional cough and mild dyspnea (respiratory). He denies nausea/vomiting (gastrointestinal). The patient reports no chest pain (cardiovascular). He says he has been feeling depressed since his diagnosis (psychiatric). The patient has no excessive sweating, urination, or thirst (endocrine).

In this scenario, the physician performed a complete ROS, as she documented pertinent positive and negative responses during the review of 11 systems.

It’s also important to keep in mind that if a patient or nursing assists the patient upon intake and completes patient history sheet/questionnaire that asks reviews the recognized systems and, the physician reviews and refers to it, this too can be counted toward the review of systems level.