Pediatric 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 providers.

Often, a lower code must be selected simply because the doctor didn't document pertinent negative responses or inappropriately used the statement "all systems negative."

Ensure you're properly counting elements of the 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, if a patient is suspected of having a bladder infection, "pertinent" refers to the genitourinary system, which means the doctor 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. An extended ROS, consisting of more than two systems reviewed, can support a level three new patient service (99203) or a level four established patient service (99214).

Complete: When the provider reviews 10 or more of 14 systems, she 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).

The following chart shows you the number of systems (out of 14 total systems) that the practitioner must review to meet each E/M level.

Learn the Systems You Will Be Counting

If the patient suffered a sprain or fracture, the pediatrician 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. These can be counted as elements of HPI, or ROS, but cannot be double-counted to support both elements.

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's mother mentions that the patient also has experienced stomach issues since starting a new vitamin. The pediatrician 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: The physician 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: Document every system you review 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 you don't document the work, you 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 an RN, LPN, or medical assistant. You may even have the parent or 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 addressed during their encounter," says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia. "I encourage this as a good way to make sure that ROS is documented completely."