tci E/M Coding Alert - 2018 Issue 8

Reader Question: Add up Negatives to Complete ROS Equation

Question: Can we count a “complete” ROS when the surgeon includes a statement such as “A 10-point ROS was negative” in the exam notes? North Dakota Subscriber Answer: No. Reporting as “negative” any number of systems fewer than 14 does not satisfy the abbreviated notation requirement for review of systems (ROS) when you’re determining the appropriate E/M level. Basis: A complete ROS means that the physician reviewed all 14 systems. But according to the 1995 and 1997 E/M Documentation Guidelines, if the physician reviews and individually documents 10-plus systems with positive or pertinent negative responses...

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