In Coding
Sep 15th, 2015
by John Verhovshek, MA, CPC Documentation stating “Family History Reviewed” is insufficient to satisfy evaluation and management (E/M) documentation requirements. 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 ...
In Audit
Sep 30th, 2013
When considering the history component of any evaluation and management (E/M) service, keep in mind the following: A chief complaint is the reason the patient feels he or she needs care. Unless the encounter is for a preventive medical history and physical, the chief complaint must be easily identifiable. This is the first step towards ...
In Coding
Jun 26th, 2013
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 ...
Nov 1st, 2012
By Angela Jordan, CPC  The key to successful electronic health record (EHR) implementation is not only selecting the right system, but ensuring you have the right people involved in the process from day one. The team should be comprised of one member from each area of the practice to represent all who ultimately must use ...
Sep 4th, 2012
When reading a chart note, it can be difficult to distinguish between elements belonging to the review of systems (ROS), and those elements that are relevant to the exam. The ROS are written or verbal “questions and answers” relevant to signs or symptoms the patient is experiencing at the time of service. Often, the ROS ...