Pulmonology Coding Alert

Hint: Guide your clinician to complete documentation of review of systems.

Ensuring your pulmonologist is documenting every aspect of the review of systems (ROS) during E/M encounters is critical to arriving at the right level office visit code. Follow these tips for accurately capturing ROS elements to avoid overcoding or undercoding E/M services.

Refresher: The third element of the history component, after the chief complaint (CC) and the history of the present illness (HPI), is the ROS — this portion of the history trips up many coders because often they must select a lower code simply because the provider inadvertently underdocumented the system review.

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 Orofino, CPC, owner of Innovative Coding Analysis in Allentown, Penn.

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: A problem-pertinent ROS occurs when the provider 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, for example, “pertinent” refers to the respiratory system which means your pulmonologist reviews at least one element within the respiratory system.

In addition to 1 HPI element, a problem-pertinent ROS supports a level two new patient E/M service (99202) or a level three established patient E/M service (99213).

Extended: When your pulmonologist conducts an extended ROS, he reviews a “limited” number of systems. According to Medicare (and most other payers), “limited” should be a total of two to nine systems including the respiratory system.

Along with 4 HPI elements and a comment in either the past, family or social history, an extended ROS can support a level three new patient service (99203) or a level four established patient service (99214).

Complete: When your provider reviews 10 or more systems, he achieves a complete ROS. Along with 4 HPI elements, and a comment in each of the past, family and social histories, 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

There are 14 systems your provider might review: constitutional; eyes; ear, nose, and throat (ENT); cardiovascular; respiratory; gastrointestinal; genitourinary, musculoskeletal; integumentary; neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic, Orofino explains.

Example: A new patient presents with complaints of wheezing and dyspnea. The patient is questioned on whether the present complaints are continuous or something that occurs when the patient undertakes some activity. Your pulmonologist then proceeds on to the exam and makes a decision from that information. This represents a problem-pertinent ROS (the respiratory system).

In the same example, your provider may also ask about fever (constitutional), rhinitis or sinusitis (ENT), chest pain (cardiovascular) and abdominal tenderness (gastrointestinal), 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” or remainder negative.”“In the past, however, some payers have disallowed this inclusive statement, and required an individual listing of systems only.”

Tip: Remind your provider to document every system he reviews so you can count it in your coding. Your pulmonologist might have the habit of only documenting positive findings, but you should make it clear that documenting pertinent negative findings is just as important for supporting the History component of the billable E/M level. If your provider doesn’t document the work, he 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

Your pulmonologist does not necessarily need to record the ROS himself. “The ROS may be documented by the patient or auxiliary staff as long as your pulmonologist initials and dates patient populated forms and states they reviewed and/or agree with this documentation,” Orofino says.

Example: ROS can be done by a physician assistant (PA), nurse practitioner (NP), ora medical assistant (MA). You may even have the patient fill out an ROS questionnaire, which the doctor reviews and signs. Your providers can use a form like the one on page 20 to personally capture the ROS, or the patient may complete the form himself. Either way, have your provider reference the ROS in the dictation, orinitial and date the form.

“I don’t feel that the doctor has to re-document the ROS, but do feel that he needs to review it with the patient,”  says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia. “It helps our doctors and nurse practitioners to have the patient fill out a questionnaire when they come to an appointment to make sure that all problems are addressed during their encounter. I encourage this as a good way to make sure that ROS is addressed and documented appropriately.”

Important: Patient-completed ROS templates may be OK, but ask your physician to make his documentation specific to each patient. Also, be sure your provider documents that the ROS was reviewed with the patient by noting any additional pertinent information.Forms completed by the patient at the initial visit can be used again during subsequent established patient visits provided that the physician reviews the initial form, updates the form with any changes, and the initials and dates the form indicating his review.

Pointer: “When a practice is under audit by an insurance company and documentation for E/M codes is requested, the forms the patient filled out, including the ROS, should be included to gain credit for the ROS unless the physician takes the visit and dictates a comprehensive overview of what is contained in the chart,” Orofino explains.