Urology Coding Alert

Ensure you have documentation of each system -- or prepare to assign a lower code.

Level-four and level-five office visits are not uncommon in a urology 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 urologist's ROS with this primer 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: A problem-pertinent ROS occurs when the urologist 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 urology practice, "pertinent" refers to the genitourinary system, says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia, which means the urologist reviews at least one item within the GU system.

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 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 including the GU system.

An extended ROS can support a level three new patient service (99203) or a level four established patient service (99214).

Although a urologist primarily treats the genitourinary system, "he has the whole picture as there may be factors that are pertinent to the urologic problem," says Ruth Borrero, claims analyst at Prohealth Care department of urology in Lake Success, N.Y.

Complete: When your urologist reviews 10 or more systems, he 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 urologist address during a ROS, is of course the genitourinary (GU) system. Examples of a GU ROS might include symptoms such as nocturia, urinary frequency, urinary pain, incontinence, hematuria, renal colic, or testicular pain, Borrero says.

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

Example: A new patient presents with incontinence. The patient is questioned on urinary pain or hematuria associated either before, during, or following the incontinence. Your urologist moves on to the exam and makes a decision from that information. This represents a problem-pertinent ROS.

In the same example, your urologist may also ask about fever (constitutional), abdominal pain (gastrointestinal), and excessive thirst (endocrine), which may result in an extended ROS.

How it works: Your urologist 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 keyword. If you don't see that sort of notation, the urologist must then document at least 10 individual systems to be able to assign a complete ROS.

Tip: Remind your urologist to document every system he reviews so you can count it in your coding. Many physicians document only positive findings, but documenting negative findings is just as important for supporting the billable E/M level. If your urologist 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

The urologist does not necessarily need to record the ROS himself. "The ROS may be documented by the patient or auxiliary staff as long as the physician/NPP initials and dates patient populated forms and 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.

"It helps our doctors and nurse practitioners to have the patient fill out a questionnaire that addresses their problems when they come to an appointment to make sure that all problems are address during their encounter," Boone says. "I encourage this as a good way to make sure that ROS is documented completely."

Stay tuned: Watch for a sample form in the next issue of Urology Coding Alert that you can use to ensure your providers capture every ROS element possible.