Published in the May 2010 issue of Today’s Hospitalist
YEARS AGO, before the Centers for Medicare and Medicaid Services (CMS) entered our lives, we learned physical diagnosis from standard textbooks like Bates and De- Gowin. History-taking and physical examination followed a time-honored script from head to toe based on patients’ presenting problems. Only later did we learn that the data that we collect and document translate into dollars and RVUs. This was an epiphany for some, a Tooth Fairy moment for others.
The problem is that the CMS doesn’t always view physical diagnosis the same way as our mentors and sage textbook authors. Differences in information architecture can have significant implications for coding and billing, particularly for higher levels of service.
Review of systems
The CMS defines review of systems 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.” It recognizes 14 individual systems. (See Table 1, below.)
Although this seems pretty straightforward, providers frequently confuse past medical history with review of systems. “Patient has CHF” or “arthritis” often wind up under the review of systems when, at least as described, they really reflect the patient’s past medical history.
To document the status of these conditions under review of systems, use symptoms, not markers of past medical history. Ask patients about symptoms related to known medical problems, such as orthopnea for heart failure and joint stiffness for arthritis. Then document patient responses to make your case.
What’s the downside of not adequately documenting the review of systems? Simply put, data are dollars. You need to review at least 10 systems to charge either a 99222 or 99223 level initial visit, so making a mistake on just one system could drop you down to the lowest level (99221). Here in Minnesota, the reimbursement difference between a 99221 and a 99223 “which may be just a matter of a few words “is about $100.
While it’s easy to get confused about what constitutes a review of systems, physical examination is where major problems can occur.
For starters, the CMS recognizes seven body areas and 12 organ systems. (See Table 2, below.) What’s the difference between these two categories? That is an impenetrable mystery that the CMS does not illuminate. Perversely, however, only organ systems can contribute toward your ability to bill a comprehensive physical exam. (For other physical exam levels, you can count either body areas or organ systems.)
Out of necessity, billing and coding wonks have come up with some working definitions to guide physicians and steer clear of auditors. One urban legend, which in this case is worth believing, holds that body areas are akin to body parts; they have no specific function and typically house other tissues and organs. By contrast, organ systems are highly organized groups of tissues that work together to perform some common function.
Providers frequently examine body areas thinking that they have addressed specific organ systems. Some body areas and standard verbiage that wind up in dictations are as follows:
- Head: normocephalic, atraumatic
- Neck: supple without thyromegaly
- Abdomen: obese\
- Back: straight without kyphosis or scoliosis
As Table 3 (below) demonstrates, you need to transmute body areas into organ systems to bill higher levels of service. For example, head needs to become eyes (“pupils equal, round, reactive to light”) and/or other organ systems contained in that region like the ears or nose. Abdomen needs to be gastrointestinal (“soft, non-tender, without organomegaly or masses”) and so on.
The safest position “at least from a coding and billing point of view “is to stick to organ systems for the physical exam. Although there are good reasons to examine body areas like the neck (for jugular venous distension, for instance), the resulting data are usually subsumed under a specific organ system (cardiovascular, in this case).
The obvious asymmetry between review of systems and physical examination is just one of many torments. Apparently, you can review the endocrine system but not examine it. “Hematologic and lymphatic” and “allergic and immunologic” are two systems when reviewed, but collapse into one when examined. Go figure.
Then there are misattribution problems, like noting that the patient is wearing eyeglasses on physical examination. (Nice try, but this should appear under review of systems.) Or the peripheral edema that’s literally under the skin is actually a cardiovascular element if due to heart failure “or musculoskeletal if secondary to fracture.
Finally, there are issues with trying to make something out of nothing. “Oriented times three” “provided you actually assessed it (wink, wink) “can be counted under either the neurologic or psychiatric examination. “Oriented to person” doesn’t cross the threshold for anything billable, is clinically dubious and simply wastes space on a page.
The bad news is that physicians have to learn how to code for these types of anomalies on a case-by-case basis. The good news is that doctors invariably perform enough work to support their intended level of service.
The best way to capture charges is to understand the CMS’ information architecture and get friendly with your coder. In many cases, hospitalists are thinking one thing and coders, following the CMS’ rubric, are thinking quite another. A little education and updating that mental script from medical school can go a long way to help you get the reimbursement you deserve.
David Frenz, MD, is a hospitalist for HealthEast Care in St. Paul, Minn., and is board certified in both family medicine and addiction medicine. He serves as system medical director for addiction medicine and can be reached at firstname.lastname@example.org. Sue A. Lewis, RN, CPC, PCS, is a compliance consultant with HealthEast Care.