Urology Coding Alert

Question: Our urologist has what I think is a bad habit of always marking “all others negative” in the electronic medical record (EMR) for his review of systems (ROS) instead of actually checking off specific boxes. Can we count this in our tally when determining the appropriate E/M code? Or do we need to convince him to mark things individually?

Louisiana Subscriber

Answer:  There currently are no numerical requirements for how many systems the physician must document in conjunction with the “all others negative” statement. The physician has the freedom to decide how many systems are pertinent to thecomplaint, based on the exam.

Because the documentation guidelines say, “positive or pertinent negative responses,” if the physician indicated positive or negative for at least one system and checked the “all others negative” box, then he has documented a complete ROS. If you want more details, you might be able to find notes about other ROS elements in the history of present illness (HPI) section of the record.

You still need one system: While the decision about ROS is ultimately the physician’s, he shouldn’t consider checking the “all others negative” box a complete ROS when he hasn’t evaluated any other systems. Without documentation of positive or negative responses to at least one system, the “all others negative” statement has no value.

You can also have a problem if a physician has a consistent pattern of checking the “all others negative” box with no variation in the ROS documentation. This is because auditors may be uncomfortable if all the charts look the same, particularly if they all have the ROS box checked. The medical necessity for a complete ROS for patients with minor complaints just isn’t there if the only ROS element in every chart is that checked box.

Remember that your physician sill needs to show medical necessity for obtaining all the review of systems. If a patient presents with an injury to her groin area and three or four ROS are marked (such as respiratory, cardiac, or ENT), no auditor will count those systems as pertinent or medically necessary because there aren’t medically necessary reasons to review those systems.