Pediatric Coding Alert

CMS has specific guidelines regarding how physicians should document a review of systems (ROS). "You need to verify that all the necessary documentation is in place," says Jamie Kurrasch, CPC, with Primary Care Partners in Grand Junction, Co.

Clarify: "A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems," the E/M Documentation Guidelines state. "At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented."