EM Coding Alert

Prevent ‘all systems negative’ notations with a comprehensive form.

An easy way to help your providers accurately document the E/M components you need to choose a code is to create a template he can follow.

As mentioned in “Solidify ROS Documentation to Support Level 4 and 5 Encounters” on page 19, some physicians forget to document negative systems in their review of systems (ROS). A simple form like this can help ensure your providers capture each and every system they review during an encounter. You can use this sample or tailor it to fit your practice’s needs.