Ophthalmology and Optometry Coding Alert

Question: If the physician examines a patient who has had an organ removed, can we still count that organ toward the physical exam or review of systems (ROS) in scoring the E/M level?

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Answer: Yes. A system is a system, not an organ. So, if you have a lung removed, you still have another one. You also have a nose, pharynx, etc. If you have a kidney removed, or even both, you still most likely have a bladder, ureters, urethra, urostomy, etc.

In other words, patients will have other organs within the system that might be very important toward the examination and the decision-making. In fact, those systems might be more important because of the lack of one of the components. Therefore, you should always continue to review the systems that are relevant to the patient's condition and count them, when medically necessary, toward the elements of E/M services when tallying the bullets.

It may also be important to remember that a missing organ may be an important aspect of the ROS by itself. Document this within the appropriate category.