Question ROS

pog

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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?
 

Pathos

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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
 

pog

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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.
 
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