Pulmonology Coding Alert

Find out the importance of documenting pertinent positive/negative responses.

Level-four and level-five office visits are not uncommon in a pulmonology practice, but if you incorrectly tally the history, exam, and medical decision-making (MDM), you will miss out on the higher level codes you could report.

The third element for the historical portion of an E/M service, after the chief complaint (CC) and the history of the present illness (HPI), is the review of systems (ROS) -- this portion of the E/M service trips up many coders because often they must select a lower code simply because the provider didn't document pertinent negative responses or inappropriately used the statement "all systems negative."

Ensure you're properly counting your pulmonologist's ROS with this tips to guarantee you're not overcoding or undercoding his E/M services.

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

Problem-pertinent ROS: A problem-pertinent ROS occurs when the pulmonologist reviews a single system during the encounter, presumably the system directly related to the problem identified in the patient's history of present illness (HPI). For a pulmonology practice, "pertinent" typically involves the respiratory system, which means the pulmonologist reviews at least one item within this system.

A problem-pertinent ROS supports a level two new patient E/M service (99202, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family) 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: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of low to moderate severity. Physicians typically spend 15 minutes faceto-face with the patient and/or family).

Extended: When the physician conducts an extended ROS, he should review a "limited" number of systems. According to Medicare (and most other payers), "limited" should be a total of two to nine systems which may include the respiratory system and at least one other system (e.g., cardiovascular).

An extended ROS can support a level three new patient service (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. Counseling and/ or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family) or a level four established patient service (99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family).

Although a pulmonologist primarily treats the respiratory system, "she considers the whole picture as there may be other factors that are pertinent to the pulmonic problem," says Ruth Borrero, claims analyst at Prohealth Care department of urology in Lake Success, N.Y.

Complete: When your pulmonologist reviews 10 or more systems, she achieves a complete ROS. A complete ROS can support a level four or five new patient E/M (99204-99205) or a level five established patient visit (99215).

Learn the Systems You Will Be Counting

One of the systems that you'll see your pulmonologist address during a ROS, is of course the respiratory system. Examples of a respiratory ROS might include symptoms such as cough, shortness of breath, hemoptysis, and wheezing.

In addition to the respiratory system, there are 13 other systems your pulmonologist might review: constitutional; eyes; ear, nose, and throat; cardiovascular; urinary; gastrointestinal; musculoskeletal; integumentary; neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic, Martin explains.

Example: A new patient presents with fatigue (780.79) and shortness of breath (786.05). The patient is questioned about other respiratory symptoms (e.g., wheezing or coughing) associated either before, during, or following the reported problems. Your pulmonologist moves on to the exam and makes a decision from that information. This represents a problem-pertinent ROS. In the same example, your pulmonologist may also ask about fever (constitutional), abdominal pain (gastrointestinal), and excessive thirst (endocrine), which may result in an extended ROS.

How it works: Your pulmonologist must individually document the systems with positive or pertinent negative responses. For any remaining systems up to the required 10, he can make a notation that all other systems are negative. "Other" is the key word. If you don't see that sort of notation, the pulmonologist must then document at least 10 individual systems to be able to assign a complete ROS.

Tip: Some payers (e.g., Trailblazers) do not permit the use of the phrase "all others negative." In this case, remind your pulmonologist to document every system she reviews so you can count it in your coding. Many physicians document only positive findings, but individually documenting negative findings is just as important for supporting the billable E/M level. If your pulmonologist doesn't document the work, she won't get credit for it. You'll have no choice but to code a lower level visit if you can't justify the ROS portion.

Determine Who Can Record the ROS

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

Example: "ROS can be done by a physician assistant (PA), nurse practitioner (NP), and sometimes a medical assistant (MA)," Borrero explains. You may even have the patient fill out an ROS questionnaire, which the doctor reviews and signs. If you'd like a sample form that you can use to ensure your providers capture every ROS element possible, email editor Claire Gamboa at cgamboa@codinginstitute.com.