ED Coding and Reimbursement Alert

Question: One of our physicians frequently forgets to check all the elements he reviewed for the review of systems (ROS). He documents level-five E/M claims, 99285, with at least two but less than 10 ROS checks. He's losing out on money, so I brought this documentation absence to his attention. Now, he wants me to bring the chart back to him if I notice a level five without proper ROS documentation so that he can check the "all others negative" box for the remaining systems. Is this ethical?

Connecticut Subscriber

Answer: You shouldn't bring the chart back to the physician to effectively add ROS points to qualify for a level five. Your physician would add an addendum only for clearly incomplete and uncodable records, for example, if the physician didn't document an ROS. In your case, inform your physician that he needs to improve documentation for ROS elements before you code. You can also give your physician a chance to look over the chart at the end of the clinical encounter to check for completion. That review will give your physician the chance to focus on documentation elements before he sends you the claims.

You Be the Coder and Reader Questions reviewed by Mike Ganovsky, MD, CPC, CFO.