kareystadler
New
When coding an invoice and there is only a few review of systems can you ask the doctor to add them?
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki Review of Systems?
- Thread starter kareystadler
- Start date
kareystadler
New
The way I understand it is that the ROS is something the doctor does face to face with the patient or a questioner that the patient fills out. If that is so then the doctor would not be able to go back and add a review of systems. I am just needed other peoples outlook or guidelines on this issue. Thank you.
Pam Warren
True Blue
You cannot ask the provider to pad his documentation just to elevate the level of E&M code. You can use those examples to teach them to document more carefully the next time, as medically appropriate.
ROS is part of the subjective portion of the note, and is the patient's response to questions asked by the provider, or from a checkoff list that has been acknowledged by the provider. More isn't necessarily better.....the system review has to be relevant to the chief complaint. Review the 1995 and 1997 documentation guidelines (from CMS), which will answer many of your questions.
ROS is part of the subjective portion of the note, and is the patient's response to questions asked by the provider, or from a checkoff list that has been acknowledged by the provider. More isn't necessarily better.....the system review has to be relevant to the chief complaint. Review the 1995 and 1997 documentation guidelines (from CMS), which will answer many of your questions.
kareystadler
New
Thank you for your response this is what I thought but need clarification on this. Thank you so much for your help.