Wiki Physical exam

[rcanales]

How many ROS need to be listed for a complete physical exam?

 

[CodingKing]

You may want to consider downloading the 1995 & 1997 Documentation Guidelines as it gives detailed information

Under History component, Complete ROS = At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.

 

[rcanales]

You may want to consider downloading the 1995 & 1997 Documentation Guidelines as it gives detailed information

Under History component, Complete ROS = At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.

Greatly appreciated! I'm New to AAPC.

 

[CodingKing]

I also wanted to add that ROS is only 1 of 3 components of the history.

History is also only one of the components of an E&M which is the talking part

Separate items need to be met in the exam portion (the touching)

Third is the MDM which is the reviewing/thinking part of the E&M