tci Part B Insider - 2011 Issue 3

Part B Coding Coach: 99214: Tally Review of Systems Accurately And You May Qualify for Higher-Level Codes

Without documentation of each system, prepare to assign a lower code.Medical practices that correctly document their visits and code based on the documentation should not shy away from reporting level-four and level-five office visits, but if youincorrectly tally the history, exam, and medical decision-making (MDM), you'll miss the opportunity to report 99214 or 99215.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 often they...

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