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E/M & ROS

Judy kay Posted Tue 22nd of March, 2011 14:09:36 PM

In order to charge a 99214 (Estab PT), does the E/M documentation need to include the ROS, in addition to the Past,Family,Social & Med HX. I was told at a Seminar that without a ROS, the highest level of E/M that can be charged is 99213. Of course, the HPI is listed (as it should be as to patient's current problem(s).

Sandra Answered Tue 22nd of March, 2011 15:45:27 PM

Regarding ROS question and 99214: There are 3 components to History documentation - HPI/status, ROS and PFSH. 3 of 3 of those components must be satisfied in order to support the level of Hx. Meaning that the lowest of any 3 of those Hx components determines the level of Hx. So in order to support a Detailed Hx (level 4 Hx) the HPI must include at least 4 elements of the presenting problem(s)or the status of 3+ problems -and- >2 / <9 ROS Q&A -and- 1 PFSH, both pertinent to the presenting problem(s). --- CMS (Medicare) Documentation Guidelines are the standard by which all third-party payer follow. However, in addition to counting elements/status, systems, hx, bullets and number of diagnosis, it all boils down to the nature of the presenting problem(s); that is, the overall risk and possible outcome. Only that which is medically necessary in order to diagnose and treat should be used when determining the level of E/M service. *** Incidentally, a level 3 Hx requires only 1 pertinent ROS.

Judy kay Posted Tue 22nd of March, 2011 16:08:05 PM

Thanks for the quick reply. But just to further clarify, for an EST Level 4 visit, 2 to 9 pertinent body systems. AND for an EST Level 3 visit, at least 1 pertinent ROS. Additionally, what part does the Medical History play in this scenario - is this also part of the HPI and does it need to be carried forward in each pt visit ?

SuperCoder Answered Wed 23rd of March, 2011 20:01:45 PM

For Level 4 visit: Past pertinent Medical History which is a must feature. But, in Level 3 visit. Although it doesn't add to any point to elevate the History level, it definitely can be considered raising the risk in the MDM.

If this is what answered to your question or something else?

Judy kay Posted Thu 24th of March, 2011 19:23:22 PM

Thanks, it is getting a little clearer. But going back to the ESTAB PT, Level 3 visiit, at least 1 ROS is required pertient to pt's complaint(s) that visit. If 2 to 9 body systems, a Level 4 can be considered based on the other documentation. The Medical History can contribute to the Decision Making. Please advise. Also, do you or anyone can a VERY SIMPLE guideline to follow when coding the E/M codes, mostly on the visits in the office for Internal & Family Practice physicians???

Kerri Answered Thu 24th of March, 2011 19:57:34 PM

You do not necessarily have to have a ROS to code for a 99214. The 3 key components used to determined an E/M level of service are: 1) History, 2) Examination and 3) Medical Decision Making (not HPI, ROS, PFSH). For an established patient visit (99211 to 99215)you only need to satisfy 2 of the 3 key components. Please note that you must have a chief complaint for any E/M service. You don't have to have ROS -- you could meet the 2 out of 3 requirements if the visit note properly documents a detailed Physical Exam and Medical Decision Making of moderate complexity. Another way to meet the requirements is based on time. For a 99214 the physician would have to be able to document that he spent at least 25 minutes with the patient and MUST show that more than 50% of the visit was spent providing counseling and/or coordination of care.

Does that help?

SuperCoder Answered Fri 25th of March, 2011 07:10:26 AM

Kerri, what I know is 2/3 key components applicable for established patient is from [History/Physical Exam/MDM] and not from [HPI/ROS/PFSH].
Do you have any source to support that 2/3 concept is applicable to HPI, ROS, PFSH?

Kerri Answered Fri 25th of March, 2011 20:12:24 PM

Actually, you are agreeing with me. My post says the 2/3 key components are HPI, PE and MDM. The original poster (above my name) indicated she thought it was HPI, ROS and PFSH.

Sandra Answered Sat 26th of March, 2011 03:53:49 AM

Hi Judy. I developed an elementary guide using real clinical scenarios typical in Internal and Family Practices, outlining the minimum documentation required within each of the 3 key components for each E/M service within the ranges 99202-99205 and 99212-99215, (and many for 99211). I would be glad to share them with you. (very basic) ** While it is true that only 2 of the 3 key components, Hx, Exam and MDM, are required to support a given level of established E/M service, obtaining some amount of Hx is typical of an E/M service, if only PF (1 element or the status of 1 chronic problem; no system inventory; no PFSH). For that matter, even if TIME is the factor in supporting a given level of E/M service, some discussion of the history of the presenting illness occurs.

Judy kay Posted Mon 28th of March, 2011 15:31:00 PM

Sandra, thank you and the other coders you were willing to help. If this guide can be faxed to my attention at (314) 352-0320 it will be very much appreciated.

Judy kay Posted Mon 28th of March, 2011 15:32:44 PM

Sandra, if this can be EMAILED, my address - judy.sandretto@swmcstl.com Forgot to include this info in message above

Sandra Answered Tue 29th of March, 2011 23:40:36 PM

Consider it done (in the morning)

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