Pulmonology Coding Alert

Transitioning to the world of Electronic Health Records (EHR) can make your coding easier on many levels, but don't take it for granted. Physicians often fall short in their review of systems (ROS) documentation, whether they use paper charts or rely on EHR, but you can help correct the deficiency.

Consider this situation and decide how you would handle it before reading on for our experts' advice.

Scenario: The pulmonology practice uses an EHR. One physician has a sheet listing any concerns or problems that the patient fills out prior to the visit. The pulmonologist uses the sheet for his (ROS) and for chart documentation. He lists anything the patient marks as positive and then states "see pt questionnaire." He then discards the form the patient completed.

Concern: If the chart is audited, would the practice be required to produce the original patient form as proof of the statement "see pt questionnaire"? Or would includinga blank form showing what each patient is given to fill out be adequate when paired with the physician's notes?

The main problem with the scenario above is the failure to save the paperwork completed by the patient if the electronic record fails to capture all of the information -- referring to the information without the patient's original responses isn't enough to cover your bases.

"A blank sheet or having nothing to support the review of systems is considered not documented," says Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CEMC, COBGC, CDERC, CCS-P, vice president of strategic development for the American Academy of Professional Coders. "The CMS guidelines are clear that there must be evidence that the information was reviewed and updated." The physician may provide this update with a personal entry of the patient-provided information, or elect to scan the patientcompleted document into the EHR.

In absence of an electronic update/entry in the EHR, evidence such as the patient form in our scenario should be kept because it's part of the medical record. "It should be scanned into their system," Grider says. "The CMS E/M guidelines for both 1995 and 1997 are very clear on this."

On the other hand, you are not required to keep the paper to prove who gave you the information, says Alan L. Plummer, MD. In fact, no such requirement is stated in the guidelines. He explains, "Not every doc uses a pt questionnaire, and they would not be required to do this or have witnessed proof of obtaining ROS. An entry in the medical record (hand-written or electronic) suffices the requirements as the doc's signature is an attestation to obtaining all information in that specific entry."

CMS establishes guidelines with Medicare patients in mind, but they can still apply to your pulmonology practice. Most private payers follow CMS's lead on coding guidelines, including documentation for ROS.

According to the CMS 1995 and 1997 E/M Documentation Guidelines, "The ROS and/or PFSH (personal family and social history) may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others."

"This guideline fits quite well in a paper chart, where the provider would review the form, sign off on it, and place it in the patient's medical record," says Colleen Wade, CPC, CPC-H, CPC-I, CEMC, PCS, FCS, a billing and coding auditor with the University of Medicine and Dentistry of New Jersey in Stratford. "The provider would then reference this form in his own note, listing any additional personally obtained findings and verification of its review without having to re-document all of the information."

You can follow the same tactics when using an EHR, Wade says.

• Confirm that the form includes elements from all ROS systems as identified in the E/M guidelines. "If this is thecase, I would then advise the pulmonologist to use only the statement 'all others negative' when all systems identified on the sheet have, in fact, been responded to by the patient with either a positive or a negative," Wade advises.
• Have the pulmonologist review the form the patient completed and sign off on it, just as he/she would with paper records. The pulmonologist should then comment on the form in the electronic note and include notations of additional personally obtained information and verification of his/her review.
• Scan the form into the EHR. "I would not recommend destroying any form filled out by the patient without first making an electronic copy, even if the provider transcribes all the information contained on it to the EHR," Wade says.

Wade also recommends reviewing your practice's questionnaire to ensure it lists all systems. "Remember, if the pulmonologist says 'all others were reviewed,' CMS is going to take the pulmonologist at his/her word and assume there was a review of 10 systems," she explains.

For example, the pulmonologist's documentation might state, "A total of 10 systems were reviewed, and with the above exceptions [indicating the pertinent positives], all others reviewed were negative." "This allows the pulmonologist an opportunity to take advantage of the CMS  caveat and to reflect the services performed accurately," Wade says. Note: The "CMS caveat" is considering an ROS of 10 of the 14 systems as supporting a comprehensive history level.

Why the steps: If going through this process seems like overkill, just remember how useful it could be down the road. "This process is beneficial when dealing with chart reviews and/or audits, and would also be valuable in case of any legal issues or questions of clinical accuracy," Wade says.

For the complete information on E/M guidelines, visit www.cms.gov/MLNEdWebGuide/25_EMDOC.asp and click on the Coding and Reimbursement section.