tci E/M Coding Alert - 2016 Issue 12

Reader Question: Use This Advice to Navigate 'Negative' E/M Notes

Question: Our physician always marks “all others negative” in the electronic medical record (EMR) for his review of systems (ROS) instead of actually checking off boxes. Can we count this in our tally when determining the appropriate E/M code? Louisiana Subscriber Answer: You may be able to find ROS elements in the history of present illness (HPI), but keep in mind that there are no numerical requirements for how many systems the physician must document in conjunction with the “all others negative” statement. It’s actually up to the doctor to decide how many systems are pertinent...

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