Evaluation and Management:
Capture Level 4 and 5 Reimbursement By Honing Your ROS Skills
Published on Fri Jan 14, 2011
Ensure you have documentation of each system -- or prepare to bill a lesser service. Level-four and level-five office visits are not uncommon in many practices, but if you incorrectly tally the history, exam, and medical decision-making (MDM), you will miss out on the higher level codes you could report. The third element for the historical portion of an E/M service, after the chief complaint (CC) and the history of the present illness (HPI), is the review of systems (ROS) -- this portion of the E/M service trips up many coders because often they must select a lower code simply because the provider didn't document pertinent negative responses or inappropriately used the statement "all systems negative." Ensure you're properly counting your physician's ROS with this primer to guarantee you're not overcoding or undercoding his E/M services. Differentiate ROS Levels "The review of systems is a subjective account of a patient's current and [...]
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