bethb
Guru
Hi.
I am looking for suggestions and input for this scenario. I am fairly new to E&M code reviews and am stumped on this.
A new patient presents to the office. I have read the documentation through and through and found that no Review of Systems was done. I asked the provider, who responded, states he did not do a review of systems. Pt is intellectually impaired and a poor historian. I have no idea now what this means for the History portion of the evaluation and management.
Is the history element booted down to problem focused because no ROS was done? I have not had a coding situation before where an ROS was NOT done.
Does anyone have any knowledge or suggestions? I'm stumped
Thank you!
I am looking for suggestions and input for this scenario. I am fairly new to E&M code reviews and am stumped on this.
A new patient presents to the office. I have read the documentation through and through and found that no Review of Systems was done. I asked the provider, who responded, states he did not do a review of systems. Pt is intellectually impaired and a poor historian. I have no idea now what this means for the History portion of the evaluation and management.
Is the history element booted down to problem focused because no ROS was done? I have not had a coding situation before where an ROS was NOT done.
Does anyone have any knowledge or suggestions? I'm stumped
Thank you!