Part B Insider (Multispecialty) Coding Alert

 9 tips to capture every relevant system

Sometimes your physician's review of systems (ROS) documentation can be a maze - but at the end of that maze can be more accurate coding and higher evaluation and management levels.

"In most instances, providers aren't saying, 'I'm asking questions about X system.' They're asking questions and the coders need to be aware of what particular system that question falls under," says Marvel Hammer with MJH Consulting in Denver.

1. Separate out eyes from ear, nose and throat. Often, coders fail to understand that eyes is one system, and so are ear, nose and throat, says Jo Anne Steigerwald, senior consultant with the Wellington Group in Valley View, OH. Some coders lump eyes and ENT into one system, and some mistakenly separate ears, nose and throat into separate systems. One mistake costs your practice money, and the other reaps wrongful reimbursement, Steigerwald notes.

2. Look up the words the physician uses so you can be sure which system a term refers to, Steigerwald urges.

3. Don't miss the endocrine system. This is one of the most frequently overlooked systems, says Steigerwald. If the physician asks questions about weight gain or loss, or dryness of skin, these are frequently dealing with the endocrine system, she explains. So do questions about whether the patient feels constantly too hot or too cold. These questions may help to identify a thyroid problem, she points out.

But by contrast, questions about dizziness, weakness, tingliness or shakiness should count towards the neurological system, Steigerwald notes. And notes about swelling under the chin or neck or skin that bruises easily should count towards the hematologic/lymphatic system.

4. Don't overlook the psychiatric system. If the physician asks questions about the patient's mood, or notes that the patient has been more cheerful or depressed lately, then you can count this towards the psychiatric system, Steigerwald says.

Don't Credit One Statement To Many Systems

5. Recognize that some questions may apply to more than one system. Muscle weakness could be a musculoskeletal or neurological issue, notes Hammer. Likewise, a question about abdominal status could relate to the endocrine system because the pancreas is there, or the concern could be gastrointestinal. A question about sleep patterns could be neurological or constitutional. But you can never credit a single statement to two systems.

If your physician is a neurologist, then a question about muscle weakness is probably neurological, and likewise an orthopedist is more likely to be asking about musculoskeletal issues, notes Hammer.

6. Avoid mistaking history for ROS. This is particularly problematic for allergy questions, according to Steigerwald. If the physician asks about allergies in general, that counts towards history. But if the physician asks about the patient's current allergic symptoms, such as sneezing, then that's a ROS question.

Also, if your practice uses a form for the patient to fill in, don't count the patient's written answers about personal or family history of certain illnesses toward the ROS, Steigerwald cautions. Make sure you don't give the physician credit for 10 systems when some of them are actually history-related.

7. Ask questions. If you're not sure why your physician asked a particular question, you should approach the physician and find out, Hammer says. Explain that you're trying to learn as a coder the physician's thought process behind asking about sleep patterns or muscle weakness.

Steigerwald recommends having lunch with the doctor now and then, and bringing multiple examples of confusing ROS notes.

8. Don't credit systems that have nothing to do with the patient's problem. If the physician uses a form or electronic record to cover as many systems as possible, you may end up with some unnecessary ROS documentation, says Hammer. For example, if the patient has a sprained ankle, the physician may not need to ask about her allergies. If you include irrelevant ROS documentation, auditors could decide you were billing for medically unnecessary services.

9. A single sentence can cover several systems - especially in the case of a long sentence with lots of commas. A physician doesn't have to use a separate sentence for each system, notes Hammer.