Orthopedic Coding Alert

If each system's not documented, get ready to assign a lower code.

If you incorrectly tally the history, exam, and medical decision-making (MDM) on an office E/M service for a new or established patient, you will miss out on the higher level codes you could report.

A subsequent element for the historical portion of an E/M service, after the chief complaint (CC) and the history of the present illness (HPI), is the review of systems (ROS) -- this portion of the E/M service trips up many coders because often they must select a lower code simply because the provider didn't document pertinent negative responses or inappropriately used the statement "all systems negative."

Ensure you're properly counting your orthopedist's ROS with this primer so you're not overcoding or undercoding his E/M services.

Differentiate ROS Levels

"The review of systems is a subjective account of a patient's current and or past experiences with illnesses and or injuries affecting any of the 14 applicable organ systems," explains Nicole Martin, CPC, manager of the medical practice management section of the Medical Society in New Jersey in Lawrenceville.

You'll need to know the differences between the three ROS levels to determining the proper level of history and  therefore, E/M code level:

Problem-pertinent: A problem-pertinent ROS occurs when the physician reviews a single system during the encounter, presumably the system directly related to the problem identified in the patient's history of present illness (HPI). For an orthopedic practice, "pertinent" refers to the nervous system, which means the physician reviews at least one item within that system.

A problem-pertinent ROS supports a level two new patient E/M service (99202) or a level three established patient E/M service (99213).

Extended: When the physician conducts an extended ROS, he should review a "limited" number of systems. According to Medicare (and most other payers), "limited" should be a total of two to nine systems including the nervous system.

An extended ROS can support a level three new patient service (99203) or a level four established patient service (99214).

Although an orthopedist primarily treats the musculoskelatal system, it is often important to understand the "larger picture," as there may be factors that are pertinent to the patient's problem. For example, the presence of urological dysfunction and visual disturbances may influence medical decision making, explains Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

When your physician reviews 10 or more systems, he achieves a complete ROS. A complete ROS can support a level four or five new patient E/M (99204-99205) or a level five established patient visit (99215).

Learn the Systems You Will Be Counting

In addition to the musculoskeletal system, there are 13 other systems your orthopedist might review: constitutional; eyes; ears, nose, and throat; cardiovascular; respiratory; gastrointestinal; nervous system; integumentary; neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/ immunologic, Martin explains.

Example: Encounter notes indicate the orthopedist treated a patient for pain in the spine and ribs following a collapse and blackout; the patient had reported having chest pain 5 minutes before the blackout; the chest pain abated postblackout, but the fall resulted in severe spine and rib pain for the patient. During the review of systems (ROS), the physician also gets positive responses when she asks the patient about head pain, dizziness, chest pain, muscle pain. The patient also had several nicks and cuts incurred from the fall that the physician asked about. Then, the physician wrote "Review of all other systems negative."

You should be able to report a complete ROS -- though you are best served to include more specific documentation about the positive ROS checks.

Do this: Make sure that you have proof of the patient's positive ROS responses in the documentation. According to your description, the physician noted positive responses for:

• musculoskeletal (muscle pain)
• neurologic (head pain, dizziness)
• cardiovascular (chest pain)
• integumentary (cuts and bruises)
• respiratory (breathing trouble).

And then: You can use the "all other systems negative" quote or check box for the rest of the claim, but remember that is a documentation exemption rather than a performance exemption. Making such a statement without actually performing a complete review of systems would be inappropriate.

The orthopedist must individually document the systems with positive or pertinent negative responses. For any remaining systems up to the required 10, he can make a notation that all other systems are negative. "Other" is the key word. If you don't see that sort of notation, the physician must then document at least 10 individual systems to be able to assign a complete ROS.

Tip: Remind your surgeon to document every system he reviews so you can count it in your coding. Many physicians document only positive findings, but documenting negative findings is just as important for supporting the billable E/M level. If your orthopedisst doesn't document the work, he won't get credit for it. You'll have no choice but to code a lower level visit if you can't justify the ROS portion.

Determine Who Can Record the ROS

The surgeon does not necessarily need to record the ROS himself. "The ROS may be documented by the patient or auxiliary staff as long as the physician/NPP initials and dates patient populated forms and states they reviewed and/or agree with this documentation," Martin says.

Example: "ROS can be done by a physician assistant (PA), nurse practitioner (NP), and sometimes a medical assistant (MA)," explains Ruth Borrero, claims analyst at Prohealth Care in Lake Success, N.Y. You may even have the patient fill out an ROS questionnaire, which the doctor reviews and signs.

"It helps our doctors and nurse practitioners to have the patient fill out a questionnaire that addresses their problems when they come to an appointment to make sure that all problems are address during their encounter," says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia. "I encourage this as a good way to make sure that ROS is documented completely