tci Part B Insider - 2014 Issue 45

Reader Question: Document An Incomplete ROS

Question: When we have an established patient that comes into our office that needs to be sent to the hospital, we don’t perform a complete review of systems. Will these be level 4 or 5 established patient office visits? Answer: As with other visits, you should determine the code selection by the visit’s documentation. You can give credit if a portion of the history was unable to be obtained because of the emergent nature of the patient’s conditions, as long as the physician indicates that within his note.  To report 99214 (Office or other outpatient...

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