Pediatric Coding Alert

Confirming that your doctor's documentation captures every system he reviewed guarantees you pick the correct E/M level.

One easy way to ensure that your pediatricians document the E/M visit components is to create a template he can follow. As mentioned in our article, "99214: Know Whether You Qualify for Higher-Level Codes," some physicians forget to document negative systems -- a simple form like this can help confirm that you capture each and every system reviewed during an encounter. You can use this sample or tailor it to fit your practice's needs.

Important: Patient-completed ROS templates may be OK, but ask your physician to make his documentation specific to each patient. Also, be sure you document that the ROS was reviewed with the patient by noting any pertinent information and initialing or signing the template.