tci Part B Insider - 2015 Issue 40

Clip And Save: Don't Forget Negative Responses in ROS Documentation

Coding a patient’s visit can be difficult when the beneficiary can’t share his history (See page 314), but even when he can, you’re still faced with other documentation issues that can trip you up. For many providers, problems can arise when the review of systems (ROS) is sparse because patients don’t report positive responses to the listed elements. However, you can still code this section if your provider remembers to document pertinent negative responses. Background: The third element for the historical portion of an E/M service, after the chief complaint (CC) and the history of...

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