Primary Care Coding Alert

Know the differences in levels to move toward correct selection.

When it comes time to calculate E/M levels, the review of systems (ROS) often trips up many coders. If you find yourself forced to select a lower code simply because your physician didn't document thoroughly, read on for some coding groundwork that will benefit everyone in your office.

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 determine the proper level of history and, therefore, correct E/M code level:

Problem-pertinent: A problem-pertinent ROS occurs when the physician reviews a single system directly related to the problem identified in the patient's history of present illness (HPI) during the encounter. Although it's easy to determine the pertinent body system for some specialties (such as the genitourinary system for urologists), no specific system leads to "pertinent" in family medicine. "You'll determine the pertinent system based on the patient's HPI," says Kent J. Moore, manager of healthcare delivery and financing systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan. For example, if the patient presents complaining of stomach pains, your pertinent system is gastrointestinal. If the patient complains of migraines, the pertinent system most likely is neurological.

A problem-pertinent ROS supports an expanded problemfocused history, which, in turn, supports a level two new patient E/M service (99202, Office or other outpatient visit for the evaluation and management of a new patient ...) or a level three established patient E/M service (99213, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components ...).

Extended: When the physician conducts an extended ROS, he should review the system directly related to problem(s) identified in the HPI and a "limited" number of other body systems. According to Medicare (and most other payers), "limited" should be a total of two to nine systems.

An extended ROS can support a detailed history, which, in turn, can support a level three new patient service (99203) or a level four established patient service (99214).

When considering ROS, the physician keeps the "whole picture" in mind, since there might be many factors pertinent to the patient's problem, says Ruth Borrero, claims analyst at Prohealth Care in Lake Success, N.Y.

Complete: When your FP reviews 10 or more systems, he achieves a complete ROS. A complete ROS can support a comprehensive history, which, in turn, can support a level four or five new patient E/M (99204-99205) or a level five established patient visit (99215).

Verify Who Records the ROS

The physician does not necessarily need to record the ROS himself or herself. "According to the Medicare documentation guidelines for E/M services, the ROS may be documented by the patient or auxiliary staff as long as the physician/NPP initials and dates patient or auxiliary staff populated forms and states they reviewed and/or agree with this documentation," Martin says.

Example: "ROS can be done by anyone from a physician assistant (PA) to a nurse practitioner (NP) to a medical assistant (MA)," Borrero explains. You may even have the patient fill out an ROS questionnaire, which the doctor reviews and signs.

Some doctors and nurse practitioners ask patients to fill out a questionnaire that addresses their problems when they come to an appointment. The step helps ensure that all problems are addressed during their encounter and helps you obtain a completely documented ROS. It's also a good way to make more efficient use of your clinical staff, Moore adds.