The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.
Review of Systems
A key component of an E&M visit is the review of systems. This component of the history section of an E&M code documents the extent of the history of present illness, review of systems, and past family, and/or social history (PFSH) that is obtained and documented. It is based upon clinical judgement and the nature of the presenting problem(s).
PATIENT’S SUBJECTIVE SYMPTOMS
Both the 1995 & 1997 Evaluation & Management (E&M) Guidelines define the Review of Systems (ROS) as, “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.” This system-by-system inquiry is focused on the subjective symptoms of the patient rather than the objective signs perceived by a clinician. I frequently hear comments from physicians indicating they do not want to write things twice. This comment is reflective of their confusion about the Assessment and Plan (A&P). It is important to note that the analysis of the patient from a clinical standpoint is not the same as the ROS, which is a documentation of the patient’s comments.
STAFF DOCUMENTATION OF ROS
The series of questions the clinician or ancillary staff asks the patient concerning each organ system and region of the body is done to gain an optimal understanding of the patient’s presenting illness and medical history. Staff can document the ROS, but the physician must document confirmation of the information or add supplemental information. The Guidelines state:
DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.
The extent of ROS (as with HPI and PFSH) is dependent on the clinical judgement and nature of the presenting problem. When I am auditing charts and find a seemingly minor presenting problem, but see an extensive or complete ROS, my comments are that the chart is either under-documented (in reflecting the severity of the patient’s presenting problem), or over-documented with regard to the ROS. Why would you need to document a ROS of 14 areas for a patient with a hangnail? If, however, the patient has a history of diabetes and has already lost a couple of fingers and a foot, then perhaps that comprehensive ROS is appropriate to be sure nothing worse is going on with the patient. Without proper documentation of the uncontrolled diabetes and previous problems, the presenting problem would seem minor and not warrant a comprehensive ROS.
One of the problems with Electronic Medical Records (EMR) is that it is very easy to click and quickly have a comprehensive ROS. But was it “necessary?” Was it appropriate based on the nature of the presenting problem as stated in the E&M Guidelines? Over documentation of a ROS can lead to a code selection that is higher than that which is “medically necessary.” When a chart is audited, medical necessity is determined by the insurer. Do not over document a ROS just because you can. Make sure the information you capture details that which you are using in evaluating the patient. Insurers have stated multiple times that information that does not appear relevant based on the documentation of the patient’s presenting problem or history will not be considered.
ALL OTHER SYSTEMS NEGATIVE
When a patient does require a comprehensive review of systems, such as when he or she is a new patient, the E&M Guidelines state:
DG: 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.
A notation of pertinent positives and pertinent negatives followed by a statement of all other systems being negative, would be counted as a comprehensive review of systems.
UNABLE TO OBTAIN HISTORY
When you are unable to obtain a ROS or other history information from the patient, do not just write “unable to obtain” the information. Document why you cannot obtain a ROS and what efforts you made in trying to obtain information (i.e. attempts to contact other family members; calls to the nursing home; review of prior records). There is no easy way to give “credit” when no elements of the history are documented. Medicare educators have stated that providers should document their efforts and the auditor/reviewer will determine how much “credit” to give for those efforts. The E&M Guidelines state:
DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history.
Although the guidelines state what needs to be documented if you cannot get a history, there is no accommodation for what should be done to get any “credit” for history. If the ROS / history element is not at a comprehensive level, visits such as a hospital admission cannot be billed in the code set as initial encounters, regardless of the level that the rest of the documentation for the visit supports.
Many physicians and auditors have believed that documentation of “unable to obtain history” gets you credit for a comprehensive history (which included a complete ROS). Unfortunately, that is a myth. I call it the Miller Myth. This is named for a dear friend who challenged me several years ago to find a reference that supported giving ANY credit for the statement “unable to obtain history.” I could not find any and honor him here for winning the challenge.