Internal Medicine Coding Alert

Hint: You could report a higher level E/M for a complete ROS.

When you’re reporting an E/M encounter performed by your clinician, keep a close eye on the number of systems he reviews. If you fail to identify the proper review of systems (ROS) level, the coding consequences could cost your practice money.

For example, if your provider performs an extended ROS, it can support up to a level-three new patient code (99203, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity), which pays about $109 (3.04 non-facility relative value units [RVUs] times the 2016 Medicare Physician Fee Schedule conversion rate of 35.8043). 

If your internal medicine provider performs a complete ROS, it can support a level-five new patient code (99205, [… a comprehensive history; a comprehensive examination; medical decision making of high complexity]), which pays about $208 (5.82 non-facility RVUs times 35.8043).

Don’t let deserved reimbursement fly out the door with shoddy ROS. Here’s some expert insight into choosing the right ROS level for every encounter.

Know Your Systems Well To Count ROS

During an ROS, “the physician asks, or reviews, the patient’s body systems looking for any problems or symptoms the patient is experiencing,” explains Cathy Satkus, CPC, coder at Harvard Family Physicians in Tulsa, Ok.

For coding purposes, CPT^® considers each of the following as body systems:

• Constitutional symptoms (fever, weight loss, etc.)
• Eyes
• Ears, nose, mouth, throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/lymphatic
• Allergic/immunologic

Once you are familiar with the different body systems, you’re ready to drill deeper into ROS with a primer on ROS levels.

Look For Problem-Pertinent ROS on Simpler Encounters

There are three levels you can choose from when deciding review of systems (ROS): problem-pertinent, extended, and complete. Your internist performs a problem-pertinent ROS when he reviews and documents all pertinent negative and positive responses for one system related to the problem during the encounter.

Depending on other encounter specifics, a problem-pertinent ROS can support up to a 99202 ( … an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making…) E/M for new patients, or a 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity…) E/M for established patients.

Count At Least a Pair of Systems for Extended ROS

You’ll choose an extended ROS when the provider reviews between two and nine systems, Satkus confirms.

An extended ROS can support up to a level-three new patient E/M service (99203, …a detailed history; a detailed examination; medical decision making of low complexity…) or a level-four established patient E/M (99214, … a detailed history; a detailed examination; medical decision making of moderate complexity…).

Warning: You should not assume that you can automatically code all extended ROS encounters with 99203 or 99214. The other elements of the encounter — the remaining history components (history of present illness and past medical, family, and social history), examination, and medical decision making — must also satisfy E/M requirements to justify your code choice.

Consider this example from Cynthia A. Swanson RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb.:

Example: A patient presents with a chief complaint of upper respiratory symptoms, including nasal discharge and an earache. She is also concerned about a recent panic attack she suffered while flying. Documentation indicates that the physician reviewed the following systems:

• Constitutional: no recent weight change
• Eyes: no vision problems
• ENT: frequent sinus pain/pressure, worse during allergy season
• Gastrointestinal: no nausea/vomiting
• Skin: no rash
• Psychiatric: panic attacks for a number of years, on Lorazapam
• Respiratory: denies shortness of breath, wheezing.

This is an extended ROS, as the physician documented positive or negative responses for seven systems.

Count 10-Plus Reviews for Complete ROS

The provider performs a complete ROS when she reviews 10 or more systems. Again, depending on the other specifics of the encounter, a complete ROS can support up to a 99204 ( … a comprehensive history; a comprehensive examination; medical decision making of moderate complexity…) or a 99205 new patient E/M, or a 99215, ( … a comprehensive history; a comprehensive examination; medical decision making of high complexity…) established patient E/M.

Consider this example of complete ROS:

Example: A new patient presents to the internal medicine physician. He just moved to the area after being diagnosed with non-Hodgkin’s lymphoma. He complains of some recent hearing loss, occasional cough, and feeling depressed since his diagnosis.

The patient generally has been feeling well other than his recent hearing loss (ears). He thinks he might be allergic to penicillin due to the rash he experienced the last time he took it (allergic/immunologic). There are traces of the rash, and he reports mild skin irritation (integumentary). His appetite and weight have been stable (constitutional). He denies headache (neurological) or visual symptoms (eyes). As noted, he has an occasional cough and also admits to mild dyspnea (respiratory). He denies nausea/vomiting (gastrointestinal). The patient reports no chest pain (cardiovascular). He says he has been feeling depressed since his diagnosis (psychiatric). The patient has no excessive sweating, urination, or thirst (endocrine).

In this scenario, the physician performed a complete ROS, as she documented pertinent positive and negative responses during the review of 11 systems.

Failure to Document ROS Can Be Very Limiting

Achieving some level of ROS requires documenting the pertinent positive and negative responses to the physician’s questions. Failure to do so can severely limit your choice of E/M codes, because as the old adage goes, ‘If it isn’t documented, it didn’t happen. Thus, no ROS limits the level of history to problem focused, and a problem focused history only supports a 99201 (problem focused history; problem focused examination; straightforward medical decision making) new patient visit or a 99212 (problem focused history; problem focused examination; straightforward medical decision making) established patient visit.

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