Primary Care Coding Alert

A lack of E/M coding smarts can cost your FP when it comes to determining review of systems (ROS) level. In some instances, it can make all the difference when choosing an E/M service.

Check out this FAQ to master all three ROS levels and become an ROS coding sure shot.

ROS is part of the history component of an E/M service. CPT defines it as "[a]n inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced."

During ROS, the physician might review systems directly related to the problem or problems identified in the history of present illness (HPI) portion of the E/M and a number of additional systems.

As CPT notes, the ROS "helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options."

"A review of body areas/systems that directly pertains to the patient's current status and well-being. It is done by physicians to help assist in defining/diagnosing the patient's complaints," explains Celia Forde, CPC, CPCH, coding specialist for Florida's Centra Care.

Example: A patient reports to the FP complaining of a headache. The FP inquires about how long the headache has lasted, and a few other questions to rule out migraines.

After the FP discovers that the patient has not taken any medication for the headaches, he prescribes severalover-the-counter options to deal with the condition, and tells the patient to come back in for another exam if the headaches worsen or increase in frequency. In this instance, the coder can only consider one system reviewed (neurological), since the FP has apparently only inquired about the system directly related to the problem.

For any one E/M service, the physician typicallyreviews at least one system. The number of additional systems the physician reviews depends on the nature of the presenting problem [NOPP], explains Kenny Engel, CPC, coding coordinator with Advanced Healthcare in Germantown, Wis.

There are three levels of ROS, and these levels can affect E/M code choice, so you need to pay attention to how many systems the FP reviews for each E/M.

According to CPT 2010, "the following elements of a system review have been identified:

• constitutional symptoms [fever, weight loss, etc.]

• eyes

• ears, nose, mouth, throat

• cardiovascular

• respiratory

• gastrointestinal

• genitourinary

• musculoskeletal

• integumentary [skin and/or breast]

• neurological

• psychiatric

• endocrine

• hematologic/lymphatic

• allergic/immunologic."

Best bet: When counting ROS, be sure to includeeach review question under one of these categories.

According to both the 1995 and 1997 CMS documentation rules, there are three different levels of ROS, and you must identify ROS level before choosing a level of history and, subsequently, an E/M code.

When the physician reviews a single system, it is a problem-pertinent ROS. This ROS level can support up to a level-two new patient E/M (99202, Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision making) or a level-three established patient service (99213, ... an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity).

When the physician reviews two to nine systems, the encounter is an extended ROS.

Extended ROS can support up to a level-three new patient service (99203, ... a detailed history; a detailed examination; and medical decision-making of lowcomplexity) or level-four established patient service (99214, ... a detailed history; a detailed examination; medical decision-making of moderate complexity).

Caveat: An extended ROS does not necessarily qualify an encounter for 99203 or 99214; though it does make reporting these codes possible.

For a complete ROS, most insurers accept a review of 10 or more systems, says Forde. The FP must individually document those systems with positive or pertinent negative responses. For the remaining systems, a notation indicating all other systems are negative is permissible. Absent such a notation, the FP must individually document at least ten systems.

With a complete ROS, reporting a 99204 (... a comprehensive history; a comprehensive examination; medical decision making of moderate complexity), 99205 (... a comprehensive history; a comprehensive examination; medical decision making of high complexity) or 99215 (... a comprehensive history; a comprehensive examination; medical decision making of high complexity) is possible -- depending on other encounter specifics.

For example, let's say the FP sees an elderly patient with multiple chronic conditions, such as COPD, CHF, hypertension, and diabetes.

In this scenario, it is entirely likely that the FP will be inquiring about 10 or more of the systems, including constitutional, eyes, cardiovascular, respiratory, integumentary, neurological, and endocrine. As noted earlier, the FP should also individually document positive and pertinent negative responses. The FP can then account for the review of the remaining systems with a notation of "all other systems negative."

If you have a CPT stickler for a payer, check its ROS requirements before coding.

"Per CPT nomenclature, a complete ROS would necessitate a review of all additional body systems. This would include 14 systems. However, the CMS Documentation Guidelines define a complete ROS as covering at least 10 organ systems," Engel explains.

Most payers are not so strict, however, and will consider the review a complete ROS after the physician reviews 10 systems.