poshley203646
Networker
We have a provider that does the CC, HPI and the PFSH but rarely the ROS. My question is would his E/M be a brief visit a 99212?
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- Thread starter poshley203646
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Pathos
True Blue
You are writing that the provider states "ROS as noted in the HPI". You can use elements in the HPI towards the ROS, as long as you are not "double dipping"; meaning you are not using elements that has already been counted towards another part of the E/M visit.
Hope that helps!
Hope that helps!
Pathos
True Blue
The components that determine any E/M visit are split up into: History, Exam and Medical Decision Making. The History component are further split up in CC, HPI, ROS and PFSH. If any of those four History components are missing, then you cannot extract a full History from that documentation, and in extension the visit as well.
However, with an Established visit, you only need 2 of the 3 E/M components (Hx, Ex or MDM), which means you can still choose the E/M level based on the Exam and MDM of that documentation visit.
Even with the ROS, you are not sharing enough information for me to make an educated guess towards any E/M level, based on the information given here.
References:
CMS E/M guidelines
However, with an Established visit, you only need 2 of the 3 E/M components (Hx, Ex or MDM), which means you can still choose the E/M level based on the Exam and MDM of that documentation visit.
Even with the ROS, you are not sharing enough information for me to make an educated guess towards any E/M level, based on the information given here.
References:
CMS E/M guidelines
poshley203646
Networker
thank you I could never get a gripe of how to determine the E/M visits. I have attended workshops but was always confused but your explanation is wonderful.
Pathos
True Blue
You're welcome!
There are several free guides to E/M documentation out there that might help you further. Note that CMS is revamping their documentation requirements significantly, so change is definitely coming.
E/M University - Free area
Noridian - E/M
AAPC E/M Presentation
CMS E/M changes for 2019 and 2021
Feel free to PM me if you have any E/M specific questions, or post them here.
There are several free guides to E/M documentation out there that might help you further. Note that CMS is revamping their documentation requirements significantly, so change is definitely coming.
E/M University - Free area
Noridian - E/M
AAPC E/M Presentation
CMS E/M changes for 2019 and 2021
Feel free to PM me if you have any E/M specific questions, or post them here.
anthia
New
Similar question. I have a provider who did a great job on the HPI for a NEW patient with a full history with complete symptoms but the ROS only states "ROS as noted in the HPI". Is the ROS statement enough to upgrade this visit from a 99201? Can I use some of the HPI, without double-dipping for the ROS?
ccollison
Networker
You can use items from the HPI towards the ROS as long as you are not double dipping. Often with a large HPI, there is something that pertains to the ROS and really belongs in the ROS. They just like to use run on sentences!!
C Collison
C Collison