Cheezum51
True Blue
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
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