Wiki E/M Coding?


Sugar Land, TX
Best answers
In an encounter if the Dr. states the patient filled out a 12 pt ROS questionnaire. He then, reviewed it and signed it. When a Dr. says he "reviewed" it, is he confirming through examination of the patient. Does this qualify for the COMP exam portion of E/M Coding? Please let me know. Thanks!
Review of systems is different than the exam. It's part of the patient's history.

A review of systems (ROS) is a list of questions related to up to 14 different body systems, that may prompt additional questions or help make decisions on any problems or to proceed with a course of treatment.


Integumentary ROS - Are you sensitive to adhesives or tape? Do you have any new lesions, sores, or spots that don't heal? Do you sunburn easily?
Hematologic ROS - Do you bleed easily? Do you bruise easily? Do you have diabetes?
Constitutional ROS - any recent weight loss or weight gain? Fatigue? Fevers, chills, or night sweats?
Psychiatric ROS - any history of anxiety or depression? Suicidal thoughts?

These are all questions that may help indiciate other factors affecting the problem or potential treatments or help lead the doctor towards a probable cause for the current issue.

If there is a single problem - usually only a simple ROS (or problem pertinent ROS) is conducted

For a comprehensive exam and complete history, a complete review of sytems (10 or more) systems is usually conducted.

As far as a patient-completed ROS. That's 100% perfectly fine. The provider should initial it and date it to indicate he/she reviewed it, and make an entry in the chart note, noting any positive responses affecting the visit, or any pertinent negative responses. He should also indicate in the chart note, that he/she reviewed the patient ROS form.

i.e. "Reviewed patient ROS Form completed 4/27/17. All 12 systems negative, except recent weight gain, night sweats, shortness of breath"

An exam is a physical examination, assessment, or measurement of areas of the body, whether it's examining the skin, listening to lungs, pressing on the abdomen, taking vital signs, assesing muscular strength and flexibility, lookin at the eyes and retinas, etc.

So an Exam and Review of Sytems are different. The provider STILL needs to examine 1 or more areas of the body, and document what was examined, whether it was normal or abnormal and what the abnormality is.
The most important thing is also to make sure the referenced form is fulled out fully. For instance a presentation i went to they mentioned a few practices where only the first page was filled out and the rest was blank :eek: