tci General Surgery Coding Alert - 2011 Issue 6

Evaluation and Management: Don't Let ROS Errors Cost You Level 4 or 5 E/M Pay

Check for documentation of each system -- or prepare to assign a lower code.Your surgery practice might see lots of level-four and -five office visits, but if you incorrectly tally the history, exam, and medical decision-making (MDM), you will miss out on the pay you deserve for higher level codes.The third element for the historical portion of an E/M service, after the chief complaint (CC) and the history of the present illness (HPI), is the review of systems (ROS). This portion of the E/M service trips up many coders because the provider may not document pertinent negative...

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