ED Coding and Reimbursement Alert

Deciphering review of systems (ROS) documentation challenges coders who struggle with the differences between ROS, the history of present illness (HPI), and the physician exam elements involved with choosing an E/M level for ED codes (99281-99285).

Coders most assuredly know that E/M levels are based on three components: history, physical exam, and medical-decision-making. Their real challenge stems from the fact that the systems referenced in the ROS portion of the E/M history component also fall under the physical exam portion of the patient encounter. For example, respiratory is recognized as a body system in the ROS. It is also considered an organ system under the elements of exam. So, several statements included in a patients chart can refer to breath. This raises a host of questions. What elements of the documentation should statements about the patients breathing support? Should they support the ROS or the exam? And what should coders do if there is an overlap between the ROS and the HPI?

Coders should remember that documentation does not have to state specifically whether the item is an ROS. Anything that meets the requirement for a system review can be counted regardless of its location in the chart, says Todd Thomas, CPC, CCS-P, president, Thomas & Associates, a reimbursement consulting firm for emergency physicians in Oklahoma City.

Think of the ROS process as an interview in which the doctor or nurse asks the patient about an organ system and the patient responds. The information could also come from a questionnaire the patient completes. In short, the responses should be, and consequently look like, statements the patient would make.

For example, if the nurse documents breath sounds normal or breath sounds bilateral, he or she obviously examined the patient to get that information, Thomas explains. An exam response or one that has a medical standard element would fall under the exam rather than the ROS. A more likely ROS statement would be difficulty breathing, if the patient has a respiratory problem or respiratory negative, if the patient has no difficulty breathing.

Keep in mind that ROS documentation is active, that is, it describes a patient having problems with a particular body system at the time of the encounter. You would not find a statement that contains no history of or history of in an ROS. It would be part of the HPI. For example, no history of asthma or no history of cardiac problems would be elements of HPI or PFSH (past, family, social history).

Be Careful With Blanket ROS Statements

Blanket statements such as doing well and all systems negative add to the coders challenge.

The all systems negative statement is an inaccurate description of a [...]