tci Part B Insider - 2010 Issue 23

Reader Questions: For Complete ROS, Check at Least 10 Systems

Question: A new patient reports to our physician with heartburn, stomach ache, and nausea. She also reports a chronic cough and trouble swallowing. The physician's notes indicate that the  atient does not have a fever, eye discharge, dysuria, headache, or a rash. The doctor also notes that the patient reports anxiety, some pain in her right shoulder, and has urinary frequency. How should I code for this visit and does it meet the ROS requirement?Answer: This encounter does meet the review of system (ROS) requirement since the physician checked and documented a total of 10 systems as follows:heartburn...

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