Awareness : OBC Tips

Coding Tip: Evaluation and Management Services

You DO NOT need to re-record a Review of Systems (ROS) if there is an earlier version available in the chart.  It is acceptable to review the old ROS and note any changes.  In order to use this shortcut, you must note the date and location of the previous ROS and comment on any changes in the body of the current note.  For example, if you are seeing an established patient in the office you can document:

  • “A complete ROS, which was performed during a previous encounter was re-examined and reviewed with the patient.  There is nothing new to add, today.  For details, please refer to my previous note in this chart, dated 11/23/2014.