Otolaryngology Coding Alert

Ensure you have documentation of each system -- or prepare to assign a lower code.

Level-four and level-five office visits are not uncommon in an otolaryngology practice, but if you incorrectly document the history, exam, and medical decision-making (MDM), you will miss out on the higher level codes you could report.

The third element for the historical portion of an E/M service, after the chief complaint (CC) and the history of the present illness (HPI), is the review of systems (ROS) -- this portion of the E/M service trips up many coders because often they must select a lower code simply because the provider didn't document pertinent negative responses or inappropriately used the statement "all systems negative."

Ensure you're properly counting your otolaryngologist's ROS with this primer to guarantee you're not overcoding or undercoding his E/M services.

Differentiate ROS Levels

"The review of systems is a subjective account of a patient's current and or past experiences with illnesses and or injuries affecting any of the 14 applicable organ systems," explains Nicole Martin, CPC, manager of the medical practice management section of the Medical Society in New Jersey in Lawrenceville.

You'll need to know the differences between the three ROS levels to determining the proper level of history and therefore, E/M code level:

Problem-pertinent: A problem-pertinent ROS occurs when the otolaryngologist reviews a single system during the encounter, presumably the system directly related to the problem identified in the patient's history of present illness (HPI). For an otolaryngology practice, "pertinent" refers to the ENT system, says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia, which means the otolaryngologist reviews at least one item within the ENT system.

A problem-pertinent ROS supports a level two new patient E/M service (99202) or a level three established patient E/M service (99213).

Extended: When the physician conducts an extended ROS, he should review a "limited" number of systems. According to Medicare (and most other payers), "limited" should be a total of two to nine systems including the ENT system.

An extended ROS can support a level three new patient service (99203) or a level four established patient service (99214).

Although an otolaryngologist primarily treats the ear, nose, and throat, "he has the whole picture as there may be factors that are pertinent to the [patient's] problem," says Ruth Borrero, claims analyst at Prohealth Care department of urology in Lake Success, N.Y.

Complete: When your otolaryngologist reviews 10 or more systems, he achieves a complete ROS. A complete ROS can support a level four or five new patient E/M (99204-99205) or a level five established patient visit (99215).

Learn the Systems You Will Be Counting

One of the systems that you'll see your otolaryngologist address during a ROS, is of course the ear, nose, and throat system. An examples of a ROS might include a symptom such as trouble swallowing.

In addition to the ear, nose, and throat system, there are 13 other systems your otolaryngologist might review: genitorurinary; constitutional; eyes; cardiovascular; respiratory;gastrointestinal; musculoskeletal; integumentary; neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/ immunologic, Martin explains.

Example: A new patient reports to the ENT with a chronic sore throat and a persistent cough. She also has trouble swallowing (ear, nose, mouth, throat.)

The notes indicate that the patient has lost weight (constitutional), and has negative responses for eye discharge (eyes), dysuria (genitourinary), headache (neurological), and rash (integumentary). The physician also notes that the patient reports anxiety (psychiatric), some pain in her right shoulder (musculoskeletal), and has urinary frequency (genitourinary).

Her blood pressure is a little elevated (cardiovascular). During this encounter, the physician checked a total of 10 systems (noted in parentheses.) Remember, you may count a single system once only; though the example mentions ear, nose, mouth, and throat, and genitourinary systems more than once, they only count once each.

On the claim, if there was medical necessity and the documentation meets all other factors (the balance of the history, exam, and medical decision-making), this level of ROS would support 99204 or even 99205 (... a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...) for the E/M.

Determine Who Can Record the ROS

The otolaryngologist does not necessarily need to record the ROS himself. "The ROS may be documented by the patient or auxiliary staff as long as the physician/NPP initials and dates patient populated forms and states they reviewed and/or agree with this documentation," Martin says.

Example: "ROS can be done by a physician assistant (PA), nurse practitioner (NP), and sometimes a medical assistant (MA)," Borrero explains. You may even have the patient fill out an ROS questionnaire, which the doctor reviews and signs.

"It helps our doctors and nurse practitioners to have the patient fill out a questionnaire that addresses their problems when they come to an appointment to make sure that all problems are address during their encounter," Boone says. "I encourage this as a good way to make sure that ROS is documented completely."

Stay tuned: Watch for a sample form in the next issue of Otolaryngology Coding Alert that you can use to ensure your providers capture every ROS element possible.