Multi-system reviews must exceed exam elements in HPI.
If you choose the wrong review of systems (ROS) level when your ED physician performs an E/M, you risk miscoding the E/M, opening the practice up to lost revenue or audit concerns.
Use System List When Compiling ROS
During the ROS, the provider "asks the patient questions about symptoms he may be experiencing. It’s part of the history, done to make sure nothing important has been missed," explains Robert LaFleur, MD, FACEP, of Medical Management Specialists in Grand Rapids, Mich.
Providers perform ROS to focus treatment options and rule out 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 physician 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.
For coding purposes, 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; and-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 ED complaining of a headache. "The headache is a symptom, but what could be causing the headache? It could be muscle tension, a hangover, an aneurysm, etc.," Gilhooly says. By asking ROS questions, physicians get a better idea of the cause of the patient’s presenting problem.
1-Complaint Visits Are Often Problem-Pertinent
Be sure to keep count of the ROS total for each E/M encounter. There are three levels of ROS. The first level is problem-pertinent, which occurs when the physician 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-three E/M (99283, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of moderate complexity ...).
Here are some examples of problem-pertinent ROS from Gilhooly:
• "Patient has a headache, and the physician asks about blurred vision." (Eyes)
• "Patient has chest pain, and the physician asks about palpitations." (Cardiovascular)
• "Patient has shortness of breath, and the physician asks if she experiences any coughing or painful respiration." (Respiratory)
Extend Your E/M Options With This ROS Level
When the ED physician reviews between two and nine systems during an E/M, she has performed extended ROS, says LaFleur.
"This means that even a single comment about two separate systems would qualify as an extended ROS," LaFleur continues.
These reviews result in detailed histories and, depending on encounter specifics, can support up to a level-four ED E/M (99284 … a detailed history; a detailed examination; and medical decision making of moderate complexity ...).
Example: A patient presents complaining of chest pain. The physician asks her about the frequency of the pain, and whether or not she has palpitations. He then asks the patient if is she is experiencing shortness of breath or nausea. In this example, the physician reviewed three systems (cardiovascular, respiratory, gastrointestinal), so this is an extended ROS.
Include Key Documentation for Complete ROS
To tally a complete ROS, the physician must review at least 10 systems, says LaFleur.
"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 physician needs to specifically document those findings," she continues.
The ED physician 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?"
"He must ask directly about each system," says Gilhooly. Even if the findings for those systems are negative, you can still count them toward total ROS.
There are several ways that the physician can appropriately document a complete ROS, LaFleur says. "The first is to list the patient’s specific responses to questions about 10 or more systems."
Example: "Patient denies fever, blurred vision, sore throat, chest pain, shortness of breath, nausea or vomiting, swollen joints, rash, headaches, or swollen glands."
This note is acceptable documentation for a complete ROS, as it proves the physician inquired directly about the following systems: Constitutional; eyes; ear, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; musculoskeletal; integumentary; neurologic;and lymphatic.
"The other option is for the provider to document pertinent positives and negatives relative to the presenting complaint, and then use a summary statement for the rest of the systems," LaFleur explains.
Example: "Admitted for chest pain, patient reports to difficulty breathing, diaphoresis, and nausea, but a complete ROS is otherwise negative." Provided the physician asks the patient direct questions about each negative system, this also satisfies requirements for complete ROS.
Remember: "The ‘all other systems negative’ shortcut in the 1995 documentation guidelines is a documentation.
Question: A patient reports to the ED with a badly injured right foot; he was using a snow plow to clear his driveway, and the plow overturned and fell on his lower body. The physician takes x-rays that confirm a closed navicular fracture with some bones out of alignment. Notes indicate a level-three E/M, and also a high level of patient pain and anxiety. To calm the patient, the physician provides 19 minutes of moderate sedation while she resets the foot and puts it in a plaster cast. There is a nurse on hand during the sedation to monitor the patient’s status. Can we report the sedation?
Answer: You should be able to report the moderate sedation separately, provided the documentation clearly indicates the presence and role of the nurse during the encounter.
Don’t forget this documentation: an "independent observer" is required for moderate sedation coding).
On the claim, report the following:
• 28455 (Treatment of tarsal bone fracture [except talus and calcaneous]; with manipulation, each) for the fracture care
• modifier 54 (Surgical care only) appended to 28455 to show that you are only coding for the initial fracture care
• 99144 (Moderate sedation services [other than those services described by codes 00100-01999], provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; age 5 years or older, first 30 minutes intra-service time) for the sedation
• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) for the E/M
• modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) appended to 99283 to show that the E/M and fracture care were separate services
• E820.0 (Nontraffic accident involving motor-driven snow vehicle; driver of motor vehicle other than motorcycle) appended to 28475, 99144, and 99283 to represent the cause of the patient’s injury
• 825.22 (Fracture of other tarsal and metatarsal bones, closed; navicular [scaphoid], foot) appended to 28455, 99144, and 99283 to represent the patient’s fracture.