Question ROS necessary?

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sherrygalla

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Hello,

Our office is currently being audited. Can someone please tell me if a review of systems is a necessary component with a 99214 code after 2021?
 
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It's not a bullet counted for office/outpatient 2021 and forward. However, it is still relevant many times. It is up to the provider's judgment if medically appropriate.

Guidelines for Office or Other Outpatient E/M Services: History and/or Examination: Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information and the patient or caregiver may supply information directly (eg, by electronic health record [EHR] portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of the level of office or other outpatient codes.

2. Is the review of systems (ROS) still required, and can a medical assistant (MA)/certified medical assistant (CMA) document it? Also, who can document the history of present illness (HPI)?

The new 2021 guidelines for office visits (99202-99215) do not require a level of ROS to meet a coding requirement. It will be performed based on what the provider determines to be medically appropriate for the encounter. Regarding who can document elements of the E/M, this information was included in the 2019 Medicare Physician Fee Schedule final rule: “We are clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.”
 
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"The extent of history and physical examination is not an element in selection of the level of office or other outpatient codes". This is from the 2021 guidelines. So the ROS is part of the history section (HPI, PFSH,ROS). While history and exam may not be used in the leveling of E/M any longer, in my opinion, you never escape documenting anything that is "medically necessary". Anything that is medically necessary should be documented. Remember, the new guidelines have been written to allow the provider to document what is medically necessary and not be unnecessarily penalized for not obtaining a pre-determined amount of information. This lead to providers "over documenting" E/M visits so they could justify billing a higher code. Now the provider can documented what is "medically necessary" without the penalty of down-coding.
 
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