Wiki Please help

[bedforak1]

Another coder and I are having different views on the review of systems for office visits. They are stating that ROS-does not have to be documented by provider. The provider has to document HPI, exam and mdm. He has signed the note.

My arguement is that she is correct, but the nurse who reviewed the ROS did not sign the note and the provider did not review and confirm the findings

Help me end the madness!

 

[sheardmd]

The ROS and/or PFSH may be recorded by ancillary stafff or on a form completed by patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.

I got the above information at a Medicare E&M meeting.

 

[bedforak1]

Thanks! That's what I thought as well.

 

[Lynda Wetter]

I do believe this is stated in the 95 guidelines.

 

[MnTwins29]

LuLu79 is correct - that is the best source for this question. Andrea, I responded to your PM.

 

[bedforak1]

Thanks everyone! I appreciate the back up.