tci E/M Coding Alert - 2019 Issue Q3

Reader Question: Review the Answer to This ROS Recording Question

Question: There is a debate in our office about who can record an ROS. Can you help us? Missouri Subscriber Answer: A review of systems (ROS) is a key component in the complex equation you use to determine an E/M level. “The ROS can be recorded by the patient or any clinical staff within the office; however, the provider’s review of information obtained in the ROS must be evident within the record in order for the coder to use it toward the justification of the code,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director compliance audit...

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