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Pulmonology Coding Alert

Coding Quiz:

Test Your ROS Knowledge

Published on Sat Oct 30, 2004

3 scenarios from our experts help you improve E/M skills

Before you report any E/M procedures, look for documentation details on the patient's presenting illness, because this will make or break your patient's complete history.

Look at these three frequently asked questions related to review of systems (ROS) to determine whether you know how to deal with the most common questions on applying a patient's complete history to select the most appropriate E/M code. Write down your responses before looking to the correct answers below. 

Editor's note: Questions and answers presented in this quiz were reviewed by Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Question 1: A new patient who is unable to communicate clearly and to explain her medical problems came in to see the pulmonologist in our practice. Her condition prevented the pulmonologist from obtaining a complete history of present illness (HPI) and ROS from her. Therefore, the pulmonologist could not develop a definite assessment or plan for her treatment.

The pulmonologist called the patient's two previous physicians to discuss her medical problems. Including face-to-face patient time (45 minutes) and telephone calls (45 minutes) to other providers, the pulmonologist spent a total of 90 minutes on this patient on the same day.

How should I charge for this scenario? Which E/M codes and modifiers should I use to justify the extra time that the pulmonologist spent on the phone with other physicians on this patient's behalf?

Question 2: Can we use nurses' notes to satisfy elements of ROS and past, family, social history (PFSH), as long as the physician documents his review of the notes?

Question 3: When a pulmonologist lists an organ system and documents past medical/surgical history instead of current signs or symptoms, can I use this as the ROS?

Question 4: A grandmother brings her granddaughter into our practice because her granddaughter has had some wheezing and coughing after exercise. The grandmother says the child has been complaining of the symptoms for the past week. The pulmonologist documents "no history of asthma." But he also notes that the patient was in the hospital to have her appendix removed after a motor-vehicle accident two years before this visit, which he believes is unrelated to the injury. Should the pulmonologist consider the history documentation part of the physician's ROS or PFSH?





Answer 1: You should bill the scenario based on the appropriate level of E/M service (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient).

Note: If you want to bill based on time, the physician must spend more than 50 percent of the total face-to-face time counseling and/or coordinating care with the patient. If your physician's encounter does not meet this requirement, you cannot bill based on time.

Extra: You also cannot bill based on time if the physician states that a communication barrier extended the face-to-face time with the patient. Communication barriers do not meet the counseling/coordinating care criteria. 

The physician may document the excessive effort of trying to get an appropriate history with the reason for excessive effort and a reason for why he was unable to obtain the full history. The physician may receive credit for the "unobtainable" history.

If the physician reports service time when the patient is not physically present, you cannot report this time to most payers.

Payers consider extra time, as noted in the example above, to be part of the pre- and postservice work associated with the payment for the evaluation and management service. 
If you submit a charge for this extra time to a payer that  does not cover the service, the carrier may hold the patient responsible for the fee. 

Answer 2: As long as the physician signs the nurse's notes and documents that he reviewed them, you can meet the requirements for ROS and PFSH with information from the nurse's notes. You'll use ROS and PFSH, along with the patient's physician-documented HPI, to decide the level of information the physician gathered about the patient's history.

The ROS is basically an inventory of the body so the physician knows where to direct the physical examination. The inventory may include evaluations of any of the following systems or parts: allergic/immunologic, cardiovascular, constitutional symptoms, ears/nose/mouth/throat, endocrine, eye, gastrointestinal, genitourinary, hematologic/lymph, integumentary, musculoskeletal, neurological, psychiatric, and respiratory.

For a problem-pertinent ROS, the physician needs to review a single system or part and will usually follow the guidelines of the evaluation and management codes 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 99203 (... a detailed history; a detailed examination; and medical decision- making of low complexity).

If the physician reviews two to nine systems, you should consider the ROS "extended," which means it usually translates to 99203. If he reviews at least 10 systems, the ROS is "complete, which may earn a 99204 (... a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity) or 99205 (... a comprehensive history, a comprehensive examination, and medical decision-making of high complexity).

A "pertinent" PFSH consists of a comment in any one of the histories - information about a patient's past health history, family history, or social history - and earns a 99203. For a "complete" PFSH, the doctor must have information that involves all three of the histories. The complete PFSH translates into 99204 or 99205.

Answer 3: Ask your pulmonologist if the past medical/surgical history constitutes an ROS. Show him the CPT guidelines and have him clarify what he believes to be a review of systems.

The CPT guidelines indicate that the past medical history indicates a patient's past experiences with an illness or injury. But, in contrast, an ROS is an inventory of questions based on the history of the patient's presenting illness.

The answers to the ROS questions determine the type and extent of the exam the pulmonologist conducts. Answering the inventory questions can provide the pulmonologist with the past medical history. Encourage your pulmonologist to indicate the systems reviewed and record the positive and pertinent negatives for each system addressed.

Answer 4: Per CPT, the ROS is "an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced." The documentation of the motor-vehicle accident doesn't fit this definition and is more consistent with CPT conception of past history, which is a review of the patient's past experiences with illnesses, injuries and treatments. Therefore, the pulmonologist could consider the comment part of PFSH.

Extra: If documentation supports medical conditions that are pertinent to the patient's present condition (that is, hypertension in a patient who has chronic obstructive pulmonary disease), some carriers allow you to assign this as part of the ROS (since it impacts the patient's condition), while others only allow you to count it toward a PFSH.

Don't miss the handy Clip and Save (Article 3) to help you report the correct E/M code and diagnosis codes every time.

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