Medicare Compliance & Reimbursement

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 you incorrectly 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 must select a lower code simply because the provider didn't document pertinent negative responses or inappropriately used the statement "all systems negative." Ensure you properly count your practitioner's ROS with this primer to guarantee you're not overcoding or undercoding his E/M services. Differentiate ROS Levels "The review of systems is a [...]