tci E/M Coding Alert - 2013 Issue 3

Key Elements: Solidify ROS Documentation to Support Level 4 and 5 Encounters

With only one countable ROS element, you will be forced to choose a lower code every time. If your provider isn’t documenting pertinent negative responses in his review of systems (ROS) documentation, your practice may be missing out on level 4 and 5 opportunities – or worse, setting yourself up for payer takebacks. The third element for the historical portion of an E/M service, after the chief complaint (CC) and the history of the present illness (HPI), is the ROS — this portion of the E/M service trips up many coders because often they must select a lower...

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