Coding from ROS

Nichole73

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My job it strictly ICD 9 coding for an insurance company. I review whole charts from providers and pull all HCC relevant codes from the chart. We have a vendor that does the same thing for us in other areas of the state. The vendor is assuring us that it is acceptable by CMS to code from the Review of Systems without any supporting documentation and allowable by ICD 9 guidelines.

Could anyone shed some light on this for me?
 

Pam Brooks

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Hi, Nichole. A couple of things come to mind. First, within the instructions of how to use ICD-9 are the steps for correct coding. Step 1 is to identify the reason for the visit, such as the sign, symptom, diagnosis and condition to be coded. From a documentation standpoint, this is typically determined through chief complaint, or nature of the presenting problem and the provider's assessment. One concern about using the ROS to abstract a diagnosis or symptom is that in some healthcare settings, system review can be obtained from a form completed entirely by the patient, and may or may not have any relationship to the presenting problem.

If we look at either CMS's 1995 or 1997 guidelines (which all payers tend to follow), the diagnosis or assessment must be accompanied by supporting documentation. So abstracting a diagnosis code from the ROS where there was no associate diagnosis, or diagnosing a condition for which there was no supporting documentation are both examples of incorrect coding.
The 1995 and 1997 guidelines both state the following:
For each encounter, an assessment, clinical impression, or diagnosis should
be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation. Note that it does not say that you can abstract this from the system review; it must be determined as part of the physician's plan. However, any diagnosis that is uncertain, allows us to code out the chief complaint or elements of the patient's history (documented by the provider as symptoms), and could be validated by comments in the system review, but it would be inappropriate to code out symptoms from the ROS that had no bearing on the providers' management plan.
I'm assuming that you are coding for physician work which requires the documentation to support the work only for that particular encounter.

The rules regarding abstraction of diagnosis codes to determine the DRG weight in the inpatient facility setting are different, and there may be cases where you would be able to abstract elements of the ROS to include into your DRG calculation.

Hope this helps. Pam
 
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