“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].
Specifically, according to the documentation guidelines, the review and update may be documented by:
- 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)