Otolaryngology Coding Alert

Don't undercode the level-4 and -5 services your ENT performs.

You already know that insurers scrutinize your practice's evaluation and management levels to see whether you-re coding more high-level E/Ms than the average ENT. Don't undercode out of fear of the auditor -- instead, get in the habit of good documentation to back up your practice's good patient service.

Evaluation and management of otolaryngology patients can be complicated business. A thorough review of systems is an everyday thing for an ENT, so make sure good documentation of ROS is routine, too.

Level-four and -five E/Ms are not that uncommon for an ENT's practice, so mastery of your doctor's review of systems is critical to backing up codes like 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity -) or 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity.-), which you probably see more often.

Comprehensive History Requires Complete ROS When your physician performs an E/M service, he conducts a review of systems as part of the patient's history. For coding purposes, the history requires all three elements -- history of present illness (HPI), review of systems (ROS), and past family and social history (PFSH) -- be met, so failing to fully conduct and document any of these areas will pull down the history level.

Therefore, the ROS helps determine patient history level, which has a great effect on the level of E/M level. If you do not know the ROS level, you will be unable to decide which level of E/M code you should use on the claim.

To claim a level-four or -five E/M, documentation must indicate a comprehensive history. That requires an extended HPI (document four of seven HPI); a complete PFSH; and a complete ROS.

The basics: The main purpose of the ROS is to be sure your ENT has missed no important symptoms,especially in areas not already covered in the HPI.

The ROS is an interview in which the physician or nurse asks the patient about a specific system and records the patient's answers. Some physicians also get ROS information from patients through a questionnaire.

CMS defines 14 systems for documentation:

- Constitutional symptoms (such as fever)

- Eyes (blurred vision)

- Ears, nose, mouth, throat (trouble swallowing)

- Cardiovascular (hypertension)

- Respiratory (shortness of breath)

- Gastrointestinal (nausea)

- Genitourinary (urine incontinence)

- Musculoskeletal (joint pain)

- Integumentary (discolored skin)

- Neurological (numbness)

- Psychiatric (depression)

- Endocrine (taking synthetic hormones)

- Hematologic/lymphatic (anemia)

- Allergic/immunologic (asthma/immunodeficiency).

Tip: The physician can hand off the ROS work. -Your ancillary staff can document your review of systems and personal, family, social history,- says Kim Garner-Huey, CPC, CCS-P, CHCC, an independent coding and reimbursement consultant in Auburn, Ala.

There are three levels of ROS: problem-pertinent, extended, and complete. If the nature of the presenting problem supports coding a level-four or -five E/M, the ROS must be at the highest level: complete.

Confirm 10+ Systems for Complete ROS For a level-four or -five visit, the ROS requirement is steep: The physician must document that he checked at least 10 systems.

Consider this 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.

Templates for success: One easy way to ensure providers document the E/M visit components is to create templates they can follow. Have your provider reference an ROS in the dictation, and initial and date the form.

What to include: -I think that a good template should really prompt the physician to put in the information specific to his practice,- says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPCCARDIO, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program. It should remind him to put in -a complete review of systems (or remind him to refer to -that patient questionnaire- that they have every patient fill out). It should remind the physician to ask about social history and family history and should lead him away from words like -non-contributory- or -unremarkable,- which are not good indicators of the service provided.-

Standard operating procedure: -An excellent template should also remind the doctor to document exam elements that are routinely performed but not always documented,- Bucknam says. And -it should remind him to list the patient's co-morbid conditions.-

ROS Templates, Yes; Cloning, No

Payers and auditors who smell cloned documentation may hit your practice with fines and refund requests.Patient-completed ROS templates may be OK, but ask physicians to make their documentation specific to each patient. Also, be sure your ENT documents that the ROS was reviewed with the patient by noting any pertinent information.

For established patients, a statement of -ROS unchanged- or -same as last visit- is not acceptable. But a statement that says -reviewed history of (date) and remarkable changes are (list changes)- is acceptable; that statement links a prior history to the current visit.However, in an audit, make sure you include the prior history in the chart papers you send to the auditor.

Negativity: Some local carriers may not accept the notation of -all other systems are negative.- CMS is reviewing the acceptability of this statement but has yet to release further information.