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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 [...]
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