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Pulmonology Coding Alert

Nail E/M Levels With ROS Documentation Skills

Published on Mon Feb 23, 2009

Beware: Multi-system reviews must exceed system elements in HPI.

Don't open your practice to lost revenue or audit concerns by choosing the wrong review of systems (ROS) level and miscoding E/M services. Use these tallyingmade- easy tips.

Use System List When Compiling ROS

An ROS is an "inventory of body systems or symptoms about which the provider asks the patient," to help the physician in establishing a diagnosis. This information is also used to assist in coding, explains Tina Bauer, RHIT, coder at Minnesota's HealthLink MN.

Providers perform an ROS to identify potential problems that were not elicited in the history of present illness (HPI) portion of the exam.

Boiled down: During the ROS, the pulmonologist is trying to "learn as much as possible about what other problems a patient has that might affect how he will treat the patient," says Catherine Brink, CMM, CPC, CMSCS, president of Healthcare Resource Management in Spring Lake, N.J.

CPT breaks the body into these systems:

• constitutional symptoms

• eyes

• ears, nose, mouth, and throat

• cardiovascular

• respiratory

• gastrointestinal

• genitourinary

• musculoskeletal

• integumentary (skin and/or breasts)

• neurologic

• psychiatric

• endocrine

• hematologic/lymphatic

• allergic/immunologic.

In short, "the ROS assists physicians as they narrow down diagnostic possibilities, and it focuses on the patient's signs and symptoms," relays Joan Gilhooly, CPC, CHCC, president of Medical Business Resources LLC, in Deer Park, Ill.

Example: A patient sees the pulmonologist complaining of shortness of breath. The dyspnea is a symptom, but what could be causing it? It could be anxiety, asthma, carbon monoxide poisoning, chronic obstructive pulmonary disease, collapsed lung (pneumothorax), congestive heart failure, hyperventilation syndrome, etc.

By performing a thorough ROS, the pulmonologist can get a better idea of what the cause is for the patient's shortness of breath.

Follow-Up Visits Are Often Problem-Pertinent

Be sure to keep count of the ROS total for each E/M encounter, as there are three levels of ROS. The first level of ROS is problem-pertinent. The pulmonologist performs this ROS when he reviews only the system related to the patient's problem. Thus, if the patient has shortness of breath, the pulmonologist may ask if the patient experiences any coughing or painful respiration.

Depending on the other encounter specifics, a problem-pertinent ROS can support up to a level-two new-patient E/M:

• 99202 -- Office or other outpatient visit for the E/M of a new patient, which requires these 3 key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision making ...

Or a level-three established-patient E/M:

• 99213 -- Office or other outpatient visit for the E/M 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 ....

According to Gilhooly, many follow-up visits for patients with stable, chronic conditions that have plans of care in place utilize a problem-pertinent ROS.

Example: The pulmonologist puts a patient with asthma on steroids and changes the patient's inhaler after an exacerbation. The patient returns the next week for a scheduled follow-up. The provider asks the patient if she is having any breathing difficulties since the medication change. This is a problem-pertinent ROS.

Extend Your E/M Options With This ROS Level

When the physician reviews between two and nine systems during an E/M, he has performed an extended ROS, Bauer says.

These reviews may result in detailed histories and, depending on the remaining encounter specifics, can support up to a level-three new-patient E/M:

• 99203 --... a detailed history; a detailed examination; medical decision making of low complexity ...

Or a level-four established-patient E/M:

• 99214 -- ... a detailed history; a detailed examination; medical decision making of moderate complexity ....

Remember: You can include the system directly related to the chief complaint, but the provider must ask questions other than those obtained in HPI. "You cannotuse the same HPI element for ROS," Brink warns.

Example: A patient presents complaining of chest pain. The pulmonologist asks the patient about the frequency of the pain, and whether or not the patient has palpitations. The pulmonologist then asks the patient if he is experiencing any shortness of breath or nausea. Beyond asking about associated signs and symptoms, the pulmonologist asks the following information:

• "Do you have or have you experienced difficulty with breathing, wheezing, chronic cough, or dyspnea on exertion?"

• "Do you have any trouble with chest pains radiating to your neck or arms when exercising or walking? Any problems with irregular heart beats or pain in your legs when walking (claudication)?"

• "Do you have any trouble with stomach pains after eating, heartburn, or change in bowel habits?"

In this example, the pulmonologist reviewed four systems (cardiovascular, respiratory, musculoskeletal, gastrointestinal), so this is an extended ROS.

Don't forget to ask the right questions to achieve a thorough ROS. The pulmonologist should ask pointed questions when conducting the ROS, recommends Gilhooly.

Bad ROS question: "Any other issues I should know about?" The pulmonologist performs pulmonary and cardiac systems review, asking several detailed questions about each system. The pulmonologist then asks the patient, "Anything else I should know about?" The patient says "no," and the physician checks "All other systems negative."

This will not qualify for a complete ROS. However, if the doctor went on to ask direct questions about eight other systems (for a total of ten systems), the encounter qualifies for complete ROS -- even if the findings for those systems were negative.

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