Oncology & Hematology Coding Alert

Keep this guide to stay on track with what constitutes levels.

When you file E/M claims, you have three options when determining the review of system (ROS) level: problem-pertinent, extended, and complete. Clip this list for a handy reference when you-re trying to remember the differences between each.

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.

Each ROS level is defined by the number of systems your physician checks during the patient encounter. Medicare defines these systems for documentation purposes:

- 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.

Check out the following ROS level definitions from the 1995 Documentation Guidelines for E/M Services.

A problem-pertinent ROS inquires about the system directly related to the problem(s) identified in the history of present illness (HPI). Documentation should include the patient's positive responses and pertinent negatives for the system related to the problem.

A problem-pertinent ROS 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, which requires these 3 key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision making ...) or a level-three established patient E/M (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 ...).

Note: Remember, however, that ROS level alone is not responsible for code assignment. The patient's past, family, and social medical history; the amount of time your physician spends with the patient; and the complexity of his medical decision making all contribute to the correct E/M code.

Time tip: If your physician documents service time when the patient is not physically present (such as the post-exam call to the other physician), you cannot report this time to most payers, says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems. The oncologist should document the patient's positive responses and pertinent negatives for two to nine systems for this level.

An extended ROS 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 a level-four established patient E/M (99214, - a detailed history; a detailed examination; medical decision making of moderate complexity -)

A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems. For this level, the oncologist must review at least 10 organ systems, and he must individually document those systems with positive or pertinent negative responses. "For the remaining systems, a notation indicating all other systems are negative is permissible," CMS's documentation guidelines say.