As providers look for more ways to maximize reimbursement for services provided, they must also consider CPT coding rules and the knowledge and skills of their medical coder and billing service. When coding a claim for medical services all coding rules and guidelines must be strictly followed.
When a doctor meets a patient for the first time, especially in the emergency department, the goal is to learn as much about the patient's present and past medical history and concerns by means of the history of present illness (HPI), review of systems (ROS) and past medical, family, and social history (PMFSH).
The doctor may ask a list of questions followed by a systematic physical exam, some are limited, others are from head to toe, depending on the individual case and circumstances, which is called review of systems (ROS). This may also be part of an annual physical examination where the doctor is trying to learn as much as possible about the patients health concerns and narrow down any medical conditions, which will then influence immediate course of action and future treatment plans.
There are three levels of system reviews (ROS):
1. problem based (only the system related to the patient’s problem)
2. extended (physician reviews several systems)
3. complete (physician must review at least 10 systems)
The medical coder
must review the patient's medical records and carefully read the doctor's entries to identify the level of ROS and complexity. For coding purposes, CPT divides the body into the following systems:
- constitutional: eyes, ears, nose, mouth, and throat
- integumentary: skin and breasts
Another area that must be carefully analyzed by the medical coder in the medical chart and then properly coded for accurate billing are unusual, emergency and increased procedural services. For example, an AMA document
speaks of coding an incident of birthing room resuscitation, provision of positive pressure ventilation and chest compressions in the presence of acute inadequate ventilation and/or cardiac output using appropriate codes. There are differences between CMS and CPT E/M guidelines and differences between the CMS and CPT requirements