Pediatric Coding Alert

Question: A pediatrician sees a patient for a problem two weeks after previously treating the patient. Does the physician need to do a new review of systems (ROS)?

Wisconsin Subscriber

Answer: Regardless of length between visits, at any encounter the physician can refer to previously recorded/completed ROS in the chart to receive credit toward a given level of history.

Documentation should identify the records and the pediatrician's review with date, and note any pertinent changes or no changes. For example, proper indication of review could read, "Please see ROS on OV dated mm/dd/yy, which I reviewed today; the only change is GI positive for diarrhea."