tci E/M Coding Alert - 2022 Issue Q1

Back to Basics: Find Answers to These 3 ROS Level Questions

Does documentation show one body system or two? The difference may cost $50. Knowing how to correctly assess the review of systems (ROS) that your emergency department (ED) physician documents can ensure valuable reimbursement. Remember, most ED evaluation and management (E/M) service levels require documentation of ROS. The absence of any could negatively impact your payment. Question 1: How Do I Know Which Elements Comprise the ROS? Answer 1: During the ROS, the provider asks the patient questions about symptoms they may be experiencing. It’s part of the history, done to make sure nothing important has been missed...

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