NOV 02, 2020
Complete Review of Systems When Not Pertinent to Exam
Question. If a technician or physician is unable to perform a complete review of systems because they are not pertinent to today’s exam, can he receive full credit for stating all others are not pertinent to the patient’s condition?
Answer. Prior to Jan 2021, to qualify for a complete ROS, ten systems must be reviewed. For established patients, you should only be reviewing what is pertinent to today’s exam, otherwise you may overinflate the level of E/M code.
After Jan 2021, only a medically relevant ROS should be documented. This may vary by physician and is not countable in an audit.
Learn more about the E/M Conquering E/M Documentation Requirements