Level-four and level-five office visits are not unusual in a urology practice, but failing to incorrectly match the history, exam, and medical decision-making (MDM) can make you miss out on the higher level codes you could report.

The third element for the historical portion of an E/M service, after the chief complaint (CC) and the history of the present illness (HPI), is the review of systems (ROS) — this portion of the E/M service trips up many coders because often they must select a lower code simply because the provider didn’t document pertinent negative responses or inappropriately used the statement “all systems negative.”

Ensure you’re properly counting your urologist’s ROS with this primer to guarantee you’re not overcoding or undercoding his E/M services.

“The review of systems is a subjective account of a patient’s current and or past experiences with illnesses and or injuries affecting any of the 14 applicable organ systems,” explains Nicole Martin, CPC, manager of the medical practice management section of the Medical Society in New Jersey in Lawrenceville.

You’ll need to know the differences between the three ROS levels to determining the proper level of history and therefore, E/M code level:

A problem-pertinent ROS occurs when the urologist reviews a single system during the encounter, presumably the system directly related to the problem identified in the patient’s history of present illness (HPI). For a urology practice, “pertinent” refers to the genitourinary system, says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia, which means the urologist reviews at least one item within the GU system.

A problem-pertinent ROS supports a level two new patient E/M service (99202) or a level three established patient E/M service (99213).

When the physician conducts an extended ROS, he should review a “limited”...