Ophthalmology and Optometry Coding Alert

Question: What are the differences among the "review of systems" levels for the E/M codes?

South Carolina Subscriber

Answer: Three ROS levels contribute to the level of history selected for an E/M service. ROS progresses from "problem-pertinent" to "extended" and "complete."

CPT has identified 14 areas of a system review: constitutional systems (for example, fever, weight loss); eyes; ears, nose, mouth and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (that is, the skin or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.

In a problem-pertinent ROS, the ophthalmologist asks questions about the system directly related to the problem identified in the history of present illness (HPI).

ROS for "eyes" includes the date of the patient's last eye exam, when the patient was last checked for glaucoma (if older than 50 years of age), current eye infections or injury, eyeglasses, contact lenses, current eye discharge or excessive tearing, pain, and visual disturbances or spots/floaters.

Some of these may be part of the presenting problem. But if the ophthalmologist reviews the eyes beyond the presenting problem (for example, "patient has worn contact lenses for the last five years"), then the additional information may be counted in the ROS.

When the ophthalmologist asks about a limited number of additional systems, he meets the criteria for an extended ROS. Important: Documentation must include positive responses and pertinent negatives for two to nine systems, according to the 1995 and 1997 Documentation Guidelines for E/M Services.

A complete ROS requires inquiring about the system(s) directly related to the problem(s), plus all other body systems. The ophthalmologist must review at least 10 organ systems and individually document those systems with positive responses and pertinent negatives. Tip: For the remaining systems, he can use a notation to indicate that all other systems are negative. Without such a notation, he must individually document at least 10 systems.

Watch for: Some local carriers may not accept the notation of "all other systems are negative." CMS has indicated that it is reviewing the continuing acceptability of this statement, but has yet to release any further information.

-- Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley and Associates in Clearwater, Fla.