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lizcon98

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I’m new to the auditing world and have a question if someone could help me. I work for Pedi Cardio & have noticed one of the providers does not mention Cardio under the ROS, she has 10 elements but cardio is not one. I’m thinking she should include cardio since that’s our specialty is this correct?
 
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There is no requirement or coding guidelines that a particular system must be included. It is up to the provider to determine what information is clinically relevant and should be included in their documentation for a given encounter. Whether or not a given system is included in the ROS would not change how the E&M service would be coded.
 
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Perhaps there is some element of a cardiac ROS contained within the HPI. As Thomas says, there is no absolute requirement to document a particular system review although it would be expected.
 
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