General Surgery Coding Alert - 2013 Issue 1
Reader Question: Ensure Providers Indicate ROS Review
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Article Overview
This reader Q&A summarizes Medicare documentation guidance for E/M visits, with emphasis on how review of systems and past, family, and social history can be captured and reviewed in the medical record. It also notes that state rules may add separate requirements for sign-off on incident-to services and mid-level provider visits. The article is aimed at coding, billing, and documentation professionals who need to understand the general framework of E/M record-keeping requirements.
Why This Topic Matters
Accurate E/M documentation affects whether history elements receive credit and whether the record supports compliant billing. The article is especially relevant for practices that use ancillary staff, patient questionnaires, or incident-to workflows.
Article Sections
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Question
Introduces the reader’s question about physician responsibility for portions of an E/M visit and whether Medicare addresses this directly.
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Answer
Summarizes the documentation guidance discussed in the article and frames the general role of ancillary staff and patient-completed information.
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Straight from the source
Presents quoted guideline language from CMS documentation guidance and highlights the source material referenced by the article.
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Watch out
Notes that state-level requirements may differ from Medicare guidance and may affect documentation or sign-off expectations for certain office-based services.
What You Will Learn
- How Medicare E/M documentation guidance addresses recording of history elements
- Why physician review of the chart matters for documentation support
- How state requirements can add separate sign-off expectations
- What general documentation topics are discussed in the 1995 and 1997 E/M guidelines
Who Should Read This
- Medical coders
- Medical billers
- Compliance staff
- Physician practices
- Documentation specialists
Codes Discussed
Code Ranges Discussed
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