“Reviewed” Isn’t Enough to Meet E/M Documentation Requirements

When documenting elements of an evaluation and management (E/M) service, a notation of “Family History Reviewed,” for instance, is insufficient to satisfy the element. Guidelines require more than a simple note of “reviewed” to fulfill the documentation requirement.

Both the 1995 and 1997 documentation guidelines specify, “A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record [emphasis added].

Evaluation and Management – CEMC

Specifically, according to the documentation guidelines, the review and update may be documented by:

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  • Describing any new ROS and/or PFSH information, or noting there has been no change in the information
  • Noting the date and location of the earlier review of systems (ROS) and/or past, family, and social history (PFSH)

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6 Responses to ““Reviewed” Isn’t Enough to Meet E/M Documentation Requirements”

  1. Maria A Ruiz says:

    Also,

    to state “father deceased, mother alive” does not substantiate a review of family history.
    he reason they have Family history is to review/ clarify/ investigate hereditary disease issues…
    a good example of family history would document what the father died from, such as Heart disease, cancer, stroke etc…

    i learned this from a Palmetto GBA Webinar on E&M documentation and Requirements.
    these webinars are free for review.

  2. Becky M says:

    Is it acceptable if a MD puts in progress note EX: Family history unknown as per patient. ??

  3. Julia says:

    Can this be documented by a staff member other than a physician/NPP?

  4. Diana says:

    Julia we just had a consulting firm perform an audit on our clinic providers and according to them, only the provider can document on the ROS.

  5. Lisle says:

    Actually the 1995 and 1997 Documentation Guidelines clearly state on page 6 that “The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.”

    The only part of the history that the provider must document themselves is the History of Present Illness.

  6. Rita Stewart, CCC says:

    What if the doctor dictates family history not on file or the ros he has noncontributory are these exceptable.

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