Seeing the "Gray" in E/M Coding, Part 2 - Review of Systems and Past Family Social History

In a previous blog I wrote, "Seeing the “Gray” in Evaluation and Management Coding – Chief Complaint and History of Present Illness," I had started a dialogue related to Chief Complaint (CC) and History of Present Illness (HPI) gray areas. In this edition I hope to continue the conversation as it relates to review of systems (ROS) and past family social history (PFSH).

ROS is generally defined as an inventory of body systems to identify signs and/or symptoms related to the chief complaint. There are 14 body systems identified in the ROS. Some documentation is straightforward and easy to identify as a related to a body system, while others are almost mythical in their ability to confuse. How do you categorize “swelling” as musculoskeletal or cardiovascular; or “headache” or “sleeping ok” as constitutional or neurological? My personal favorite is what classified as an allergic ROS?

How about the often misused and misunderstood phrase “all others negative?” Many coders and coding educators have taken a very conservative approach and will not allow this documentation shortcut because of what they consider to be physician over-use. I recently reviewed a physician’s records and noted that the same two ROS (cardiovascular and respiratory) and a check next to “all others negative” were always documented regardless of the chief complaint. My opinion was that this ROS documentation did not meet the criteria for a Complete ROS.

Documentation of a complete ROS in both the 1995 and 1997 Documentation Guidelines state: “At least ten organ systems must be reviewed. Those 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, at least ten systems must be individually documented.”

What if the physician documents this for a CC of Fever: ROS: no cough or SOB, all others negative. Is this a complete ROS? My experience is NO. With a CC of fever, pertinent ROS would include at least ENT, Respiratory, Cardiovascular, and GI and if at least a total of ten different systems are reviewed then the “all other systems are negative” phrase would support a complete ROS. If we use this criteria and only count “all others negative” when pertinent we can appropriately audit and more importantly educate our physicians on the finer points of documentation as it relates to coding.

Let’s not forget the final area of gray in History coding and audit--“non-contributory.” Admittedly I am not a big fan of the phrase when used in ROS. My question to the physician who uses it is “do you mean you asked and they were negative; or are the undocumented ROS not related to the CC and therefore were not asked?” When “non-contributory” is used to document Family History, however, I do count it because there are times that the patient’s family history is non-contributory to the CC, yet in order to meet the requirements of a Comprehensive History (for example 99232 or 99233) reference to Family History must be documented. Although it does make you wonder--does the physician really need to know how a 95 year old’s father died?

I know that your may approach these issues differently and I look forward to hearing from you on your thoughts and approaches so please comment.

Next time, we will discuss other gray areas in the E/M areas.

Written by Laurie Desjardins