ED Coding and Reimbursement Alert

ROS level helps to determine E/M level on your claims When your physician performs an evaluation and management service, he conducts a review of systems (ROS) to check on the condition of the patient's body systems. If coders do not know the level of ROS the physician performs, they will be unable to decide which level of E/M code they should use on the claim.

The basics: -An ROS is a set of questions the physician asks that inquire about each system of the body. The main purpose of the ROS is to be sure no important symptoms have been missed, especially in areas not already covered in the history of present illness (HPI),- says Rebecca Parker, MD, FACEP, chair of ACEP's Coding and Nomenclature Advisory Committee, and president of Team Parker LLC, a coding, billing and compliance consulting firm in Lakewood, Ill.

The ROS is essentially an interview in which the physician or nurse asks the patient about a specific system and records the patient's answers. Some physicians also get ROS information from patients via a questionnaire.

-CMS specifically defines 14 systems for documentation purposes,- Parker says. Those systems are:

- 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.

There are three levels of ROS: problem-pertinent, extended and complete. The level of ROS will determine your E/M code choice, so you need to know the requirements for each type of ROS your physician may perform. Choose Problem-Pertinent for Minimal System Checks If your physician performs a problem-pertinent ROS, it means that he reviewed one system for the patient during the E/M. A problem-pertinent ROS will support up to a level three. Consider this example:

A patient is vacationing and pesents for suture removal from an uncomplicated wound that was repaired in his hometown ED. The chart simply states, -No complaints of wound redness- for the ROS.

On the claim, you should report 99281 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a problem-focused history; a problem-focused examination; and straightforward medical decision- making) for the service. Tread Carefully When Choosing E/M Level for  Extended ROS If you are coding for an extended ROS, the physician has to document that she -inquired about the system directly related to the patient's problem and a limited number of additional systems,- says Michael A. Granovsky, MD, CPC, FACEP, president of Medical Reimbursement Systems Inc., an ED coding and billing company in Woburn, Mass.

According to Medicare guidelines, -the patient's positive responses and pertinent negative responses for two to nine systems should be documented.- An extended ROS will support up to a level-four service, depending on the specifics of the encounter.

Consider this example from Parker:

A renal colic patient reports complaining [...]