ROS under 2023 E/M guidelines

[JRae5M]

I am encountering physician E/M notes without any ROS being documented.
Even though the 2023 E/M guidelines now state a "medically appropriate history and/or examination" is required,
does this mean that a physician who is billing outpatient can just skip this? I believe that the taking of a "history"
would still require a ROS, or am I wrong? Any guidelines would be appreciated.

 

[amyjph]

No, it's not required. It's up to the provider but not an element of choosing the E/M code.

https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

History and/or Examination►E/M codes that have levels of 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 theservice. 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 these E/M service codes.◄

 

[JRae5M]

I totally get the new E/M guidelines; I have to use them every day. Thank you for the reply...
It prompted my thinking...I guess my question goes more to whether the documentation without any ROS is adequate to communicate appropriate clinical care.
It seems to be within the realm of a peer review to answer the question whether the documentation is supporting the clinical requirements for the diagnosis.

 

[Orthocoderpgu]

I totally get the new E/M guidelines; I have to use them every day. Thank you for the reply...
It prompted my thinking...I guess my question goes more to whether the documentation without any ROS is adequate to communicate appropriate clinical care.
It seems to be within the realm of a peer review to answer the question whether the documentation is supporting the clinical requirements for the diagnosis.

I would educate your providers to document anything that they feel is "medically necessary". No a ROS is not required, if the provider truly feels that, but it does need to be documented when medical necessity is there. That is beyond a coder's skills. With 1995 & 1997 guidelines the providers were documenting more than they needed to just to justify the code. That does not need to happen any longer. I think the providers should be thrilled that guidelines are in their favor for once and they only need to document what they truly feel is medically necessary.

 

[kdlberg]

It is not required. However, I would recommend to a provider that, at the absolute minimum, they should be documenting a review of the system(s) related to the chief complaint. This is one of those things I'm sure they're doing, but maybe they think because it's not required to write down, they don't need to do it. As the compliance officer, I'm always thinking about "will this hold up in a legal situation?"