Wiki ROS/Meds as part of audit

[Cheezum51]

I just wanted some thoughts on how much of the ROS should be documented under the 2021 E/M guidelines in regards to performing a "medically appropriate history and exam." This question is in regards to eye care exams.

I feel that, for a comprehensive established patient exam, the provider should document a fairly complete ROS, or at least note no changes in ROS/meds from a recent exam, especially for patients who are taking several different medications. For brief/urgent care type visits, I think it's more appropriate to do a minimal ROS, perhaps just related to the presenting problem.

Tom Cheezum, OD, CPC, COPC

 

[csperoni]

My understanding of those changes are to allow each clinician to perform (and document) whatever they believe to be medically appropriate. Whether the clinician reviews 1 system, or all 12 systems, it does not affect the code choice. I don't question my clinician's medical decisions (at least not out loud).

 

[pvrossow]

A formally documented ROS is not necessary. Providers may deem other documented parts of the history (eg. HPI, PFSH) as sufficient to qualify as a medically appropriate history.

 

[jkyles]

A formally documented ROS is not necessary. Providers may deem other documented parts of the history (eg. HPI, PFSH) as sufficient to qualify as a medically appropriate history.

The practitioner also decides what - if any - history is medically appropriate under the new guidelines.