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Dorthi

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Ok so I have a Dr that for an ADD refill which would be a very low office visit, will have 1 paragraph but throw in under ROS 12 points reviewed all wnl. without that it is easy a 99212, can that one thing change it to a higher billing state?
 
No- History, physical exam and MDM are the core factors when coding an E/M. My opinion is there is no medical necessity for this Dr. to be charting 12 ROS elements for a ADD.
 
Ros

I would agree that a 12 point ROS would be a bit much... however, I would not be surprised to see a 3-5 system ROS. Medications that treat ADD are not without side effects. There is even a black box warning on some for the potential for abuse and/or cardiovascular reactions. I would hope that a provider would minimally evaluate the patient's appetite, weight, growth, cardiovascular, neurologic and psychiatric systems for potential side effects known to be associated with these drugs.
 
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