Part B Insider (Multispecialty) Coding Alert

If you're trying to reach the requirement of 10 organ systems in the Review of Systems for evaluation and management coding , can you use information that was also recorded in the History of Present Illness?
 
Yes, according to the American College of Emergency Physicians. ACEP has on its Web site correspondence from CMS that, while somewhat ambiguous and not binding, seems to support this interpretation. But when the rubber hits the road, "the real answer is, it depends what the carrier says," says David McKenzie, ACEP director of reimbursement.

And the carriers provide not just contradictory, but savagely confusing, guidance on this topic. Here's a sampling of two head-scratching carrier dictates:

HealthNow NY noted in its November 2003 bulletin that Medicare said in both 1995 and 1997 that a complete ROS "inquires about the system(s) directly related to the problem(s) identified in the HPI plus all the additional body systems. Thus, HealthNow concluded that if three organ systems were involved in the HPI, "these would not be excluded for the total count of ten required" for the ROS. The main factor in counting items is whether the physician recorded clinically meaningful information that is "reasonable and necessary" to develop a plan for managing the patient's complaints.

NHIC said in September 2003 that the HPI "cannot be counted towards the review of systems." But if the HPI addresses more than the four organ systems required, then "a system credit may be given for review of one system."

But Judy Richardson from Hill & Associates in Wilmington, NC comes down very strongly in NHIC's side. "You can't 'double dip' by using the same elements for the HPI and the ROS," she insists. "What most auditors do is look first for the HPI. Once they've found those, they will generally use any other elements for the ROS."

But North Augusta, SC conding consultant Susan Callaway comes down strongly against the NHIC interpretation. "In a complicated case, the physician may review five or more systems in his HPI," she notes. "If those systems are excluded from use in the total count, then there are not 10 remaining for ROS, and that makes it impossible to reach a complete ROS in the most complicated cases, where it is most indicated."