Physical components

Tricia13

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Okay, so to make sure I understand and that it's understood what I'm asking is that CPT defines a preventative medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction, and etc. So the history is a compenent of an annual examination. My question is does the ROS have to be a part of the history as in a problem oriented visit or just the past history or is it defined? Thanks for your input.
 
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Appropriate history

There are no specific guidelines for preventive exams as there are for sick visits.

The requirement per CPT is that the service be age and gender appropriate.

Do you need an ROS for a well-baby visit on a 2-month old? Probably not much of one.

Do you need an ROS for a 40 YO patient you haven't seen in a year? I would think you would. How else will you discover those "little things" that patients never come to see you for but which might portend something more serious.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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