E&M Guidelines

ON a 99203 ROS on any other that say 2-7 systems is 2 sufficient or do you have to address 7.

Sep 5th, 2012 - nmaguire 2,606

re: E&M Guidelines

Extended ROS– Problems in HPI, plus a limited number of additional systems. 99203 History:
1. Document Chief Complaint
2. Document HPI - ensure to include 4+ elements describing the HPI
3. Document ROS – problem pertinent system review extended to include a review of a limited number of additional systems,(example 2-9 systems).
4. Document PFSH – only requires one.

Sep 5th, 2012 - rphelps 615 1

re: E&M Guidelines

When you say 2-9, do we have to review 9 or is 4 adequate?

Sep 5th, 2012 - nmaguire 2,606

re: E&M Guidelines

4 is adequate

Sep 6th, 2012 - Codapedia Editor 1,399

re: E&M Guidelines

There are a lot of articles in Codapedia about auditing:

http://codapedia.com/article_140_Auditing-the-exam-1995-Guidelines.cfm

http://codapedia.com/article_87_Review-of-Systems.cfm

http://codapedia.com/article_128_Past-medical-family-and-social-history.cfm

This one by Jennifer Schmutz is good

http://codapedia.com/article_499_Elements-of-a-Complete-Medical-Record.cfm