February 2001 page 11-end
Coding Consultation
Evaluation and Management, Comprehensive Level (Q&A)
Question
How many systems must be reviewed and documented for a comprehensive level history? Also, can the physician indicate that systems are negative?
AMA Comment
Based on the 1997 Medicare Documentation Guidelines, a comprehensive level evaluation and management service includes performance of a general multi-system examination or a complete examination of a single organ system.
A complete review of systems (ROS) inquires about the system(s) directly related to the problem(s) identified in the history of the present illness, plus all additional body systems. Based on the...
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