EM Coding Alert

Question: There is a debate in our office about who can record an ROS. Can you help us?

Missouri Subscriber

Answer: A review of systems (ROS) is a key component in the complex equation you use to determine an E/M level.

“The ROS can be recorded by the patient or any clinical staff within the office; however, the provider’s review of information obtained in the ROS must be evident within the record in order for the coder to use it toward the justification of the code,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director compliance audit at Cancer Treatment Centers of America. “The important piece for the coder is to be able to see the provider’s review of the questions, the performance of the questioning, and/or the inclusion of that information in the note,” Hauptman adds.

This concurs with the Centers for Medicare and Medicaid Services (CMS) Documentation Guidelines for Evaluation and Management Services, which states that your practice “must provide a notation supplementing or confirming the information recorded by others to document that the physician reviewed the information” (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf).