Psychiatry Coding & Reimbursement Alert

Hint: You could report a higher level E/M for a complete ROS.

When your clinician performs an E/M service, you are at risk of losing out on deserved pay if you make errors in the number of systems he reviews. Get a grip on understanding how to identify the proper review of systems (ROS) level and avoid chances of deserved reimbursement sliding away from you.

For example, if your psychiatrist performs an extended ROS, it can support up to a level-three new patient code (99203, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity…), which pays about $109 (3.04 non-facility relative value units [RVUs] times the 2016 Medicare Physician Fee Schedule conversion rate of $35.8043).

If your psychiatrist performs a complete ROS, it can support a level-five new patient code (99205, … a comprehensive history; a comprehensive examination; medical decision making of high complexity…), which pays about $208 (5.82 non-facility RVUs times $35.8043).

Don’t let deserved reimbursement fly out the door with shoddy ROS. Here’s some expert insight into choosing the right ROS level for every encounter.

Know Your Systems before Performing ROS Count

During an ROS, “the physician asks about, or reviews, the patient’s body systems looking for any problems or symptoms the patient is experiencing,” explains Cathy Satkus, CPC, coder at Harvard Family Physicians in Tulsa, Ok.

For coding purposes, CPT^® considers each of the following as body systems:

• 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

Once you are familiar with the different body systems, you’re ready to drill deeper into ROS with a primer on ROS levels.

Look For Problem-Pertinent ROS on Simpler Encounters

There are three levels you can choose from when deciding review of systems (ROS): problem-pertinent, extended, and complete. Your psychiatrist performs a problem-pertinent ROS when he reviews and documents all pertinent negative and positive responses for one system related to the problem during the encounter.

Depending on other encounter specifics, a problem-pertinent ROS can support up to a 99202 ( … an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making…) E/M for new patients, or a 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:an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity…) E/M for established patients.

Count At Least a Pair of Systems for Extended ROS

You’ll choose an extended ROS when the provider reviews between two and nine systems, Satkus confirms.

An extended ROS can support up to a level-three new patient E/M service (99203) or a level-four established patient E/M (99214, … a detailed history; a detailed examination; medical decision making of moderate complexity…).

Warning: You should not assume that you can automatically code all extended ROS encounters with 99203 or 99214. The other elements of the encounter — the remaining history components (history of present illness and past medical, family, and social history), examination, and medical decision making — must also satisfy E/M requirements to justify your code choice.

Consider this example that will give you an idea about choosing an extended ROS:

Example: An established patient with bipolar disorder and several medical conditions, including diabetes and asthma, presents complaining of marital problems, insomnia, and minimal medication side effects. Documentation indicates that your physician reviewed the following systems:

• Constitutional: no fever or other constitutional symptoms
• Eyes: no vision problems
• Psychiatric: report of recent panic attack
• Respiratory: denies shortness of breath, wheezing
• Endocrine: denies excessive thirst or urge for urination.

This is an extended ROS, as your clinician documented positive or negative responses for five systems.

Count 10-Plus Reviews for Complete ROS

The provider performs a complete ROS when she reviews 10 or more systems. Again, depending on the other specifics of the encounter, a complete ROS can support up to a 99204 ( … a comprehensive history; a comprehensive examination; medical decision making of moderate complexity…) or a 99205 new patient E/M, or a 99215, ( … a comprehensive history; a comprehensive examination; medical decision making of high complexity…) established patient E/M.

Consider this example of complete ROS:

Example: A new patient presents to your psychiatrist. He just moved to the area after being diagnosed with non-Hodgkin’s lymphoma. He complains of feeling depressed since his diagnosis as well as recent hearing loss and occasional cough. He has a history of diabetes mellitus, arthritis, hypertension, and coronary artery disease.

As noted, the patient reports recent hearing loss (ears). His appetite and weight have been stable (constitutional). He denies headache (neurological) or visual symptoms (eyes). As noted, he also has an occasional cough and also admits to mild dyspnea (respiratory). He denies nausea/vomiting (gastrointestinal). The patient reports no chest pain (cardiovascular). He says he has been feeling depressed since his diagnosis (psychiatric). The patient has no excessive sweating, urination, or thirst (endocrine). He does admit to some joint pain associated with his arthritis (musculoskeletal).

In this scenario, your clinician performed a complete ROS, as she documented pertinent positive and negative responses during the review of 10 systems.

Failure to Document ROS Can Be Very Limiting

“Achieving some level of ROS requires documenting the pertinent positive and negative responses to the physician’s questions,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Failure to do so can severely limit your choice of E/M codes, because as the old adage goes, ‘If it isn’t documented, it didn’t happen’,” Moore adds. Thus, no ROS limits the level of history to problem focused, and a problem focused history only supports a 99201 (… a problem focused history; a problem focused examination; straightforward medical decision making…) new patient visit or a 99212 (…a problem focused history; a problem focused examination; straightforward medical decision making…) established patient visit.