tci ED Coding & Reimbursement Alert - 2001 Issue 4

Solve ROS Documentation Mystery Watch for Language Clues And Win the Reimbursement Prize

Deciphering review of systems (ROS) documentation challenges coders who struggle with the differences between ROS, the history of present illness (HPI), and the physician exam elements involved with choosing an E/M level for ED codes (99281-99285). Coders most assuredly know that E/M levels are based on three components: history, physical exam, and medical-decision-making. Their real challenge stems from the fact that the systems referenced in the ROS portion of the E/M history component also fall under the physical exam portion of the patient encounter. For example, respiratory is recognized as a body system in the ROS. It is also...

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