Internal Medicine Coding Alert

Published on Fri Jun 05, 2009 PDF

Is your physician reviewing information? Document it.

An ROS 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, says Stephanie Jones, CPC, CEMC, vice president of product management with the American Academy of Professional Coders (AAPC) in Salt Lake City. This may occur when a physician updates her own record, or in an institutional setting or group practice where many physicians use a common record. 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; and

" Noting the date and location of the earlier ROS and/or PFSH.