tci ED Coding & Reimbursement Alert - 2003 Issue 6

Reader Question: Give Docs a Last-Chance Look-Over

Question: One of our physicians frequently forgets to check all the elements he reviewed for the review of systems (ROS). He documents level-five E/M claims, 99285, with at least two but less than 10 ROS checks. He's losing out on money, so I brought this documentation absence to his attention. Now, he wants me to bring the chart back to him if I notice a level five without proper ROS documentation so that he can check the "all others negative" box for the remaining systems. Is this ethical? Connecticut SubscriberAnswer: You shouldn't bring the chart back to the physician...

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