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 capture the ROS, but do feel that he needs to review it with the patient to determine their level of care," says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia.

Important: Patient-completed ROS templates may be OK, but ask your physician to make his documentation specific to each patient. Also, be sure your provider documents that the ROS was reviewed with the patient by noting any pertinent information.

Pointer: "When a practice is under audit by an insurance company and documentation for E/M codes is requested the forms the patient filled out, including the ROS, should be included to gain credit for the ROS unless the physician takes the visit and dictates a comprehensive overview of what is contained in the chart," says Nicole Martin, CPC, manager of the medical practice management section of the Medical Society in New Jersey in Lawrenceville.