Evaluation and management codes

Evaluation and management (E/M) documentation has many moving parts. There are three key components that go into choosing the appropriate level of E/M services:

1. History

2. Examination

3. Medical decision making

Then there are components within these components within these components. With so much information to document, you can bet your student loan balance that you’ll forget something. 

When it comes to the history portion, the piece that clinicians tend to forget most often is the ROS (review of systems). Unfortunately, forgetting ROS can lead to down-coding of an E/M visit. 

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Here’s how ROS works

ROS is an inventory of body systems that you get from asking patients about their symptoms. There are 14 different body systems. Depending on which type of ROS you’re completing, you may ask your patient about one, some, or all of these systems.

The three types of ROS

You’ve got three levels of ROS to choose from: 

1. Problem pertinent: Only asks about the body system that’s directly related to the patient’s problem in the History of Present Illness (HPI).

2. Extended: Asks about the body system that’s directly related to the patient’s problem plus a limited number of other systems, but no more than nine.

3. Complete: Inquires about the body system that’s directly related to the patients problem plus at least 10 other systems. You only need to document positive and pertinent negative responses. With most carriers, you can simply note “all other systems are negative.” 

Test your knowledge

You can test your knowledge of E/M coding by taking a short Academy quiz, or see other coding quizzes.

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