Internal Medicine Coding Alert

Published on Mon Feb 02, 2009 PDF

Beware: Multi-system reviews must exceed exam elements in HPI.

Don't open your practice to lost revenue or audit concerns by choosing the wrong review of systems (ROS) level and in turn miscoding the E/M with these tallying made-easy tips.

Use System List When Compiling ROS

An ROS is an "inventory of body systems the provider asks the patient about," to help the physician in establishing a diagnosis. This information is also used to assist in coding, explains Tina Bauer, RHIT, coder at Minnesota's HealthLink MN.

Providers perform ROS to identify any potential problems that they did not spot in the history of present illness (HPI) portion of the exam.

In short: During the ROS, the internist is trying to "learn as much as possible about what other problems a patient has that might affect how he will treat the patient," says Catherine Brink, CMM, CPC, CMSCS, president of Healthcare Resource Management in Spring Lake, N.J.

CPT breaks the body into these systems:

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.

"The ROS assists physicians when they are narrowing down a diagnosis, and it usually focuses on the patient's signs and symptoms," relays Joan Gilhooly CPC, CHCC, president of Medical Business Resources LLC, in Deer Park, Ill.

For example, a patient reports to the internist complaining of a headache. "The headache is a symptom, but what could be causing the headache? It could be muscle tension, a tumor, a hangover, an aneurysm, etc.," Gilhooly continues. By asking ROS questions, the internist can get a better idea of what the cause is for the patient's presenting problem.

Follow-Up Visits Often Problem-Pertinent

Be sure to keep count of the ROS total for each E/M encounter, as there are three levels of ROS. The first level of ROS is problem-pertinent. The internist performs this ROS when he reviews only the system related to the patient's problem.

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

Here are some examples of problem-pertinent ROS from Gilhooly:

"Patient has chest pain, and the internist asks about palpitations." (Cardiovascular)

"Patient has shortness of breath, and the internist asks if she experiences any coughing or painful respiration." (Respiratory).

According to Gilhooly, many follow-up visits for patients with plans of care in place result in problem-pertinent ROS.

Example: The internist puts an asthma patient on steroids and changes his inhaler settings after an exacerbation. The patient returns the next week for a scheduled follow-up. The provider asks the patient if he is having any breathing trouble since his medication change. This is a problem-pertinent ROS.

Extend Your E/M Options With This ROS Level

When the internist reviews between two and nine systems during an E/M, he has performed an extended ROS, Bauer says.

These reviews result in detailed histories and, depending on encounter specifics, can support up to a level-three new patient E/M (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 …).

Remember: You can include the system directly related to the chief complaint, but the provider must ask questions other than those obtained in HPI. "You cannot use HPI info for ROS," Brink warns.

Example: A patient presents complaining of chest pain. The internist asks her about the frequency of the pain, and whether or not she has palpitations. He then asks the patient if she is experiencing shortness of breath or nausea. Beyond asking about associated signs and symptoms, the internist asks the following information:

"Do you have or have you experienced difficulty with breathing, wheezing, chronic cough, or dyspnea on exertion?"

"Do you have any trouble with chest pains radiating to your neck or arms when exercising or walking? Any problems with irregular heart beats or pain in your legs when walking (claudication)?"

"Do you have any trouble with swallowing, stomach pains after eating, heartburn, or change in bowel habits?"

In this example, the internist reviewed three systems (cardiovascular, respiratory, gastrointestinal), so this is an extended ROS.

Include Key Documentation for Complete ROS

To tally a complete ROS, the internist must review at least 10 systems, says Bauer.

"The physician has to document all positive findings, plus any pertinent negative findings" for complete ROS, Gilhooly says. "If the symptom is problem-pertinent, the internist needs to specifically document the findings," she continues.

The internist should ask pointed questions when conducting the ROS, recommends Gilhooly.

Good ROS question: "Have you had any recent feelings of hopelessness, anxiety, or irrational fear?"

Bad ROS Question: "Any psychiatric issues I should know about?"

Example: The physician performs musculoskeletal and neurologic system reviews, asking several detailed questions about each system. He then asks the patient "Anything else I should know about?" The patient says no, and the physician checks "All other systems negative."

This will not qualify for complete ROS. "He must ask directly about each system," says Gilhooly. If the internist went on to ask direct questions about eight other systems, the encounter qualifies for complete ROS -- even if the findings for those systems were negative.