• Established Patient ROS Documentation

    Question: Is there a specific amount of review of systems (ROS) we should be documenting for established patients?

    Answer: When billing established patient E/M codes, you should only be reviewing what is pertinent to today’s exam. It may only be eyes, or eyes plus another system. By documenting a complete ROS each encounter, you may be overinflating your level of service selected. 

    Learn more about E/M in the Learn to Code the Essentials.