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Pediatric Coding Alert

Reader Question:

Include This Info in ROS Update

Published on Mon Nov 03, 2008

Question: A pediatrician sees a patient for a problem two weeks after previously treating the patient. Does the physician need to do a new review of systems (ROS)?Wisconsin SubscriberAnswer: Regardless of length between visits, at any encounter the physician can refer to previously recorded/completed ROS in the chart to receive credit toward a given level of history.Documentation should identify the records and the pediatrician's review with date, and note any pertinent changes or no changes. For example, proper indication of review could read, "Please see ROS on OV dated mm/dd/yy, which I reviewed today; the only change is GI positive for diarrhea."
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