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 [...]