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Orthopedic Coding Alert

E/M Coding:

Use ROS Smarts to Accurately Choose High-Level E/Ms

Published on Thu Mar 24, 2011

If each system's not documented, get ready to assign a lower code.If you incorrectly tally the history, exam, and medical decision-making (MDM) on an office E/M service for a new or established patient, you will miss out on the higher level codes you could report.A subsequent 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're properly counting your orthopedist's ROS with this primer so you're not overcoding or undercoding his 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 [...]
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