• Dilation Pertaining to Review of Systems

    Question: Our physician was told that regardless if the patient is new or established, you need at least 10 review of systems records documented if the patient is dilated.  Is this true?

    Answer: Dilation is based on why the patient presents and the clinical expertise of the physician. It is not based on the review of systems – this is part of E/M coding audit tool for history component. 

    Learn more about exams in the 1-Hour Coding Course: E/M Documentation Guidelines for All Subspecialties