tci Outpatient Facility Coding Alert - 2017 Issue 1

You Be the Coder: Just How Many Systems' Review Suffices For a Complete ROS

Question: Instead of checking off boxes in the electronic medical record (EMR) for his review of systems (ROS), the provider just marks “all others negative” instead. Can we count on this for reporting a proper E/M code? Mississippi Subscriber Answer: There is no specific number of systems the provider needs to document alongside the “all others negative” statement. It’s actually left to the provider’s discretion — how many systems can be associated to the complaint. Because the documentation guidelines state, “positive or pertinent negative responses,” if the physician indicated positive or negative for...

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