Part B Insider (Multispecialty) Coding Alert

Without documentation of each system, prepare to assign a lower code.

Medical practices that correctly document their visits and code based on the documentation should not shy away from reporting level-four and level-five office visits, but if you incorrectly tally the history, exam, and medical decision-making (MDM), you'll miss the opportunity to report 99214 or 99215.

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 practitioner'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 doctor 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 instance, in a urology practice, "pertinent" refers to the genitourinary system, says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia, which means the urologist reviews at least one item within the GU 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, "limited" should be a total of two to nine systems including the GU system.

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

Complete: When your physician 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

An orthopedic surgeon, for instance, would typically address the musculoskeletal system during a ROS. Examples of a musculoskeletal ROS might include symptoms such as poor range of motion, joint pain, dislocation, or muscle stiffness, among others.

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

Example: A new patient presents with knee pain. The patient is questioned on the timing of the pain, whether it is worse upon climbing stairs, and whether it involves the hip, ankle, or other structures. The patient mentions that she also has experienced stomach issues since starting a new vitamin. Your doctor moves on to the exam and makes a decision from that information. This represents a problem-pertinent ROS. In the same example, your doctor may also ask about fever (constitutional), the abdominal pain (gastrointestinal), and excessive thirst (endocrine), which may result in an extended ROS.

How it works: Your doctor must individually document the systems with positive or pertinent negative responses. For any remaining systems up to the required 10, he can make a notation that all other systems are negative. "Other" is the key word. If you don't see that sort of notation, the doctor must then document at least 10 individual systems to be able to assign a complete ROS.

Tip: Remind your doctor to document every system he reviews so you can count it in your coding. Many physicians document only positive findings, but documenting negative findings is just as important for supporting the billable E/M level. If your physician doesn't document the work, he won't get credit for it. You'll have no choice but to code a lower level visit if you can't justify the ROS portion.

Determine Who Can Record the ROS

The physician 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). 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."