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Question:

My providers sometimes use a review of systems that is currently unobtainable. Can you get still reach a comprehensive history with that? I know providers shouldn’t be penalized for not getting a review of systems, but should they be rewarded with a comprehensive level?

B. Long
Compliance Auditor
Illinois

Response:

There are several different answers to this question. Some Medicare Administrative Contractors (MACs) have clarified this question, while others have not. In the case where there is not a clarification, Centers for Medicare & Medicaid Services (CMS) guidelines should be followed.

CMS guidelines state: “If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition which precludes obtaining a history.” There is no further information as to what level of review of systems should be assigned when the review of systems is unobtainable.

WPS
WPS does have the following clarification (available at www.wpsmedicare.com/j8macpartb/resources/provider_types/2009_0526_emqahistory.shtml):

“Q 2. Where does it state that if the history is unobtainable you cannot automatically bill a comprehensive history? Do you automatically have to bill based on a problem-focused history?

A 2. There is nothing notated in the 1995 or 1997 Documentation Guidelines to indicate any level of history is automatic. The physician should document the reason the patient is unable to provide history and document his/her efforts to obtain history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available), and using information contained therein to document some of the history components (past medical, family, social).

Q 3. We are unable to obtain history as the patient is intubated. Do we have to bill a Not Otherwise Classified (NOC) code?

A 3. You would only submit a NOC code when you are unable to document any of the history elements. If you are talking to the patient’s family or others to obtain history, document the work performed and code based on the work performed.”

Palmetto
Palmetto offers the following clarification (available at http://palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Railroad%20
Medicare~Resources~FAQs~EM%20Help%20Center~8EEM9H8774?open&
navmenu=%7C%7C):

“Question: When the history of present illness (HPI), review of systems (ROS) and past/family/social history (PFSH) are unobtainable, does a physician have to document the reason why or can it be inferred by other documentation within the history of present illness (HPI) (eg, patient had severe dementia)?

Answer: The documentation must clearly reflect:

• The components that were unobtainable (HPI, ROS, and PFSH)
• Circumstances that preclude obtaining the HPI, ROS and PFSH (dementia, sedated or a vent, etc). When using ‘poor’ historian the documentation must support why (e.g. dementia).
• Attempt to obtain from other resources: No family members were present to provide information; The medical record (chart, ambulance run sheet, etc) did not contain the information needed.

If patient or family can provide information at a later time, the provider may add an addendum containing information.”

Noridian
Noridian has the following information (available at https://med.noridianmedicare.com/web/jeb/education/act/act-qa-041615):

“Q6. Does a physician have to document the reason why the history of present illness (HPI), review of systems (ROS), and past/family/social history (PFSH) were unobtainable or can it be inferred by other documentation within the history of present illness (HPI) (eg, patient intubated, had severe dementia, etc)?

If unobtainable from the patient, does a physician have to document their attempt to obtain the information from other sources (eg, family, other medical records, etc)?

If unobtainable from any source, what level of history can be assigned?

A6. Per CMS 1995/1997 Evaluation and Management guidelines, see resources: Evaluation and Management.

‘If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history.’”

Other MACs
The remaining MACs offer no further guidance on the topic of review of systems unobtainable. It is recommended that the question be submitted to the appropriate MAC for clarification. According to CMS Coding and Documentation Guidelines, it would not be appropriate to automatically assign the ROS as comprehensive when the items cannot be obtained. It is recommended that the provider obtain any information from the family, previous medical records, nursing facility, ancillary staff, ambulance staff, etc. The medical record can include an addendum when the information becomes available.

— Becky Rodrian, CCS-P, CPC, CEMC, CPEDC, MBS, CBCS, BSN, is director of professional consulting services for Panacea Healthcare Solutions, Inc.

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