Otolaryngology Coding Alert

Question: Our otolaryngologist always marks “all others negative” in the EMR for his Review of Systems (ROS) instead of actually checking off boxes. Can we count this in our tally in determining the appropriate E/M code?

Codify Subscriber

Answer: You may be able to find ROS elements in the history. The history includes three elements: History of Present illness (HPI), Review of Systems (ROS) and Past, Family and Social History (PFSH).  But keep in mind that there are no numerical requirements for how many systems the physician must document in conjunction with the “all others negative” statement. It’s actually up to the doctor to decide how many systems are pertinent to the complaint.

Because the documentation guidelines say, “positive or pertinent negative responses,” if the physician indicated positive or negative for at least one system and checked the “all others negative” box, then he has documented a complete ROS.

You need that one system: While the decision about ROS is ultimately the physician’s, he shouldn’t consider checking the “all others negative” box a complete ROS when he hasn’t evaluated any other systems. Without documentation of positive or negative responses to at least one system, the “all others negative” statement has no value. Keep in mind that if you document “all other systems negative,” the reviewer won’t know whether all the other systems were reviewed or contributory. It is recommended that the practice use the following statement if you only want to indicate the pertinent positives and want a global statement to cover all the pertinent negative systems reviewed: “All other systems reviewed and negative or non-contributory.” This tells the reviewer that the provider not only is indicating that the other systems are negative or non-contributory, but that all these systems were actually reviewed them with the patient.

Note that only the HPI must be documented by the doctor when it comes to documenting a history. The ROS and PSFH can be documented by ancillary staff such as medical assistants and the provider needs to indicate they reviewed this documentation.

You can also have a problem if a physician has a consistent pattern of checking the “all others negative” box with no variation in the ROS documentation. This is because auditors may be uncomfortable if all the charts look the same, particularly if they all have the ROS box checked. The medical necessity for a complete ROS for patients with minor complaints just isn’t there if the only ROS element in every chart is that checked box.

Remember that there still has to be medical necessity for obtaining all of the review of systems. If a patient presents with an ear infection and three or four ROS are marked (such as musculoskeletal, cardiac, integumentary, or abdominal), no auditor will count those systems as pertinent or medically necessary because there aren’t medically necessary reasons to review those systems in the absence of comorbid conditions.