Question:
Answer:
This encounter does meet the review of system (ROS) requirement since the physician checked and documented a total of 10 systems as follows:Tip:
Remember, you can only count a single system once. Even though gastrointestinal and genitourinary systems were mentioned more than once, they only count once each. If the documentation does not specifically mention findings for 10 systems but the physician's note includes a statement that "all other systems were negative" then it can qualify as a Complete ROS.On the claim, if documentation meets all other factors (history and exam), you would report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; a comprehensive examination; medical decision making of moderate complexity ...) or even 99205 (... medical decision making of high complexity ...) for the E/M.