Neurology & Pain Management Coding Alert

Question: If an initial history and ROS have been documented, is it necessary to document them in detail again during each visit, or can the physician simply mention that they have not changed from the previous visit?

Oklahoma Subscriber
 
 
Answer: To claim that a history has been legitimately taken, the chart must be reviewed for family and social history, as well as a history of present illness. For the current visit the physician might write, reviewed chart for history and add if anything was new or had changed since the previous visit.
 
The review of systems (ROS) is different: You can only claim a review for systems asked about during the current visit. This is not difficult because there is usually some type of ROS. Asking if there are any allergies, for example, is considered an ROS for the immunology. Only claim what is documented. Keep in mind that unnecessary services cannot be rendered to code a higher level. Medical necessity should determine the procedures and level of E/M service provided.