Documenting a 99214: Review of Systems
To support a 99214, the medical record must typically* contain information about at least two of these systems. The recognized systems are as follows: constitutional, cardiovascular, respiratory, ENMT, musculoskeletal, psychiatric, GI, GU, neurological, allergic/immunologic, integumentary, eyes, endocrine, and hematological/immunologic.
The documentation guidelines have a provision which establishes that the medical record must typically* contain at least ten of the review of systems elements or documentation of all positives, pertinent negatives and a statement establishing that “all others are negative” in order to establish the review of systems necessary to support a comprehensive level of history. This is the ROS level required for a 99215, not a 99214. Cardiologists sometimes document the ROS is “non-contributory.” Several Medicare contractors have asserted that the term “non-contributory” is not acceptable for documenting past history, family history or social history because they interpret those statements to mean that the physician did not feel it was pertinent to inquire about those history elements. The same logic might be applied to similar comments for the review of systems. Because of this, I don't recommend documenting anything as non-contributory.
While it is not uncommon for other elements of documentation to fall short during an audit, the ROS is typically not a limiting factor. To the contrary, most 99214 notes contain way more information about the ROS than is needed to support a 99214. ROS is generally the most over documented element in 99214 notes. There is no billing benefit associated with documenting more than two ROS elements for a 99214. It is fine to do so if it clinically important and an accurate representation of the patient interview but make sure your notes do not looked "cloned." Medicare has repeatedly announced that they feel cloning medical record entries is on their radar and that it is an inappropriate use of electronic medical record (EMR) programs.
Many EMR programs facilitate carrying information forward from one visit note to the next with a few clicks. As a future post will illustrate, this is typically inappropriate.
Promotional Message: Physician education and periodic audits are highly-beneficial in three ways. Touch base with me if you would like to discuss them.