Practice Management Alert

Ensuring your physician's documentation captures every system he reviewed guarantees you pick the correct E/M level.One easy way to ensure your physician documents the E/M visit components is to create a template he can follow. As mentioned in "Capture Level 4 and 5 Reimbursement By Honing Your ROS Skills" in Medical Office Billing & Collections Alert Vol. 11, No. A, some physicians forget to document negative systems -- a simple form like this can help ensure your doctor captures each and every system he reviews during an encounter. You can use this sample or tailor it to fit your practice's needs.Your physician can use a form like the one on the next page to capture the ROS, or you can have the patient fill out the form. Either way, have your provider reference the ROS in the dictation, and initial and date the form."I don't feel that the doctor has to [...]