Wiki Review of systems problem- please help!

[1formissy]

I am hoping someone can shed some light on a problem I have with the ROS DG.

I have been an E/M auditor for many years, however, there has been some arguments between physician's and auditors with regards to the statement "...all other systems negative" for a complete ROS.

We have some provider's who document full ROS on ALL of their E/M records. It has always been a practice of mine, to review the ROS as being pertinent to the patient's presenting problems, and I have educated physicians whom I have instructed to report only those systems which are directly related to the presenting problems.

Here is an example:
Patient presents to the office with complaint of cough, and chest pain.

Checked ROS is pulmonary, and CV. Then the note says, "All other systems are reviewed and are negative."

My question is, " How would a full ROS be warranted for these complaints?"

We cannot deny based off medical necessity, we have to audit according to what is documented. Would those of you who are seasoned auditors allow a full ROS for this type of encounter?

Any help is greatly appreciated!

 

[thomas7331]

I hear what you're saying and see this a lot too, as I imagine many auditors do. The guidelines do state that this is acceptable documentation for a complete ROS. If the provider has stated that they reviewed all systems and put their signature on it, and you are not permitted to discount this based on medical necessity, then I don't see any other option than to count this as a complete ROS.

Certainly most providers are not going to do a full ROS to treat minor ailments and I've even seen this statement in my own records of visits to providers where I know first-hand that a complete ROS was not done. But I think it's an unfortunate fact of life now that E&M documentation has come to this and providers put statements like this in their notes routinely to prevent auditors from penalizing them for minor technicalities.

Medical necessity is really the only good solution to this - to educate providers that documentation should reflect what was actually done and involve providers in the discussion of ensuring that both the documentation and coding reflect a level of service that's appropriate to the presenting problems. It's much easier said than done, but I would encourage you to incorporate some form of accounting for medical necessity into your organization's auditing practice. Payers are certainly doing this now and if your internal auditing is not identifying potential upcoding because you're coding and auditing too strictly off of the documentation elements, then you're increasing your risk if audited.

 

[1formissy]

Thomas,

Thank you so much for your input. It makes it quite difficult as the payer, to advise the physician that a full ROS is not pertinent to the patient's presenting problems. I have incorporated this into my audits for the last several years and have not had a problem until one physician, (physician's wife), decided to challenge it.
If I took that review to our Medical Director, I am confident that he would agree when the patient has a limited problem and a full ROS was documented.

When we see a comprehensive exam for limited problems, we tend to pay the lesser E/M allowed amount, based off that, so I would assume that could also be exercised into the ROS issue.

I hope in the near future CMS updates some of their guidelines to be more clear and concise so that payers and providers can have a better relationship.

Thanks again, your info was refreshing and most helpful.

 

[thomas7331]

I agree with you 100% - there is a great need for better and more transparent guidelines for E&M auditing. I've actually written an article expanding my thoughts on this a bit more - it's supposed to be published in next month's AAPC magazine if you'd like to take a look, I'd love to hear your feedback.

In my experience with CMS audits of E&M services, I've found they put very little emphasis on the history and exam portions of the documentation. On codes where they reduce the level, it's always because of the MDM or the presenting problem. I've never seen them take down a level because some element was missing in the exam or history. In fact, I've seen cases where an exam was clearly 'detailed' rather than comprehensive but because the MDM and the problem were sufficiently high, they allowed the higher level code to stand. Their primary concern seems to be that the level not exceed was is reasonable and necessary to treat the condition that is documented. But it would certainly be nice if they did publish their expectations and not continue to keep us guessing!

 

[1formissy]

Well said, Thomas!

With the new classification of diseases and medical procedures the guidelines are past due for an update. 1994 was quite a long time ago, and look how far medicine has advanced since then.
I look forward to reading your article and would love the opportunity to provide my feedback.

Cheers!