Focus on Review of Systems
April 2012
REIMBURSEMENT OF EVALUATION AND MANAGEMENT SERVICES VARIES FROM LEVEL TO LEVEL
There are different levels of Evaluation and Management (E/M) services and reimbursement varies from level to level. The level selected for billing is based on your documentation. In general, the more complex the visit, the higher level of code can be assigned. E/M services are comprised of three key components: history, physical, and medical decision making. The first component, history, includes the chief complaint, the history of present illness, review of systems, and past, family and/or social history. The purpose of this newsletter is to provide you with documentation tips focusing on the review of systems. These documentation tips will help you get credit for the work you do!
REVIEW OF SYSTEMS (ROS) – WHAT YOU NEED TO KNOW:
What is ROS?
ROS is an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced.
ROS can be obtained from an earlier encounter.
• Requirements: written evidence that the physician reviewed and updated the previous information. This can be done by describing any new ROS or noting that there has been no change in the information.
Recommendation: Note the date and location of the earlier ROS.
ROS may be recorded by ancillary staff or on a form completed by the patient.
• Requirements: documentation must support that the physician reviewed the information and it must include a notation supplementing or confirming the information recorded by other.
Unable to obtain ROS from the patient or another source?
• Requirements: describe the patient’s condition or other circumstance in the medical record that prohibited the ability to acquire ROS.
Levels of ROS
1. Problem pertinent: Requires review of one system related to the current problem(s)
2. Extended: Requires review of two to nine systems
3. Complete: Requires review of at least ten systems
Complete ROS:
The Evaluation and Management Guidelines from the Centers for Medicare and Medicaid Services (CMS) states, “A complete ROS inquires about the system(s) directly related to the problem(s) identified in the history of present illness plus all additional (min 10) organ systems. Those systems with positive or pertinent negative responses must be individually documented.” For the remaining systems, per CMS, “…a notation indicating all other systems are negative is permissible. In the absence of such notation, at least ten systems must be individually documented.” Refrain from using “unremarkable,” “non-contributory,” or “all systems reviewed” without identifying whether they were negative or not.
Examples:
• Constitutional: Weight stable, patient is fatigued.
• Eyes: Loss of peripheral vision.
• Cardiovascular: Experiencing palpitations, denies chest pain, denies calf pain, pressure or edema.
• Respiratory: Shortness of breath on exertion.
• Gastrointestinal: Appetite good, denies heartburn and indigestion and has episodes of nausea. Bowel movement daily, denies constipation or loose stools.
• Musculoskeletal: Stiffness in multiple joints.
• Urinary: Denies incontinence, frequency, urgency, nocturia, pain, or discomfort.
• Skin: Clammy, moist skin.
• Neurological: Has recently fainted, denies numbness, tingling, and tremors.
• Psychiatric: Denies memory loss or depression. Mood pleasant.
SUMMARY:
Don’t risk having your E/M report down-coded due to lack of documentation supporting the ROS you have actually performed.
• You do not need to re-document a certain ROS if it was previously documented in the patient’s medical record. However, you would need to document the date and location of the previous ROS and comment on any changes.
• You do not need to personally obtain the ROS. It is permitted to either let the patient fill out a ROS questionnaire or have your staff record it. However, you still must review the information and comment on it in the medical record.
• Systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating “all other systems are negative” is permissible. In the absence of such a notation, for a complete ROS, at least 10 systems must be individually documented.
(Note: The above rules for documenting the ROS are identical for both the 1995 and 1997 E/M guidelines.)
If there is a topic that you would like to see covered, please contact Wendy Block at wblock@prcmedical.com or by phone, 330.564.2618.