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General Surgery Coding Alert

Evaluation and Management:

Don't Let ROS Errors Cost You Level 4 or 5 E/M Pay

Published on Fri May 13, 2011

Check for documentation of each system -- or prepare to assign a lower code.Your surgery practice might see lots of level-four and -five office visits, but if you incorrectly tally the history, exam, and medical decision-making (MDM), you will miss out on the pay you deserve for higher level codes.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 the provider may not document pertinent negative responses, or may inappropriately use the statement "all systems negative." Use the following ROS primer to guarantee you're not overcoding or undercoding your surgeon's E/M services.Differentiate ROS Levels"The review of systems is a subjective account of a patient's current and or past experiences with illnesses and or injuries affecting any of the 14 applicable [...]
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