Part B Insider (Multispecialty) Coding Alert

Published on Mon Jan 24, 2011 PDF

Confirming that your doctor's documentation captures every system he reviewed guarantees you pick the correct E/M level.

One easy way to ensure that your physicians document the E/M visit components is to create a template he can follow. As mentioned in our article, "99214: Tally Review of Systems Accurately And You May Qualify for Higher-Level Codes," some physicians forget to document negative systems -- a simple form like this can help confirm that your doctor captures each and every system he reviews during an encounter. You can use this sample or tailor it to fit your practice's needs.

Important: Patient-completed ROS templates may be OK, but ask your doctor to make his documentation specific to each patient. Also, be sure your physician documents that the ROS was reviewed with the patient by noting any pertinent information