Can the Review of Systems (ROS) and/or Past, Family, Social History (PFSH) sections of the History component of an Evaluation and Management (E/M) be recorded by ancillary staff?
Yes, according to the 1995 E/M Documentation Guidelines, The ROS and/or PFSH section of the history component of an E/M may be recorded by ancillary staff. There must be a notation supplementing or confirming the information that was recorded by the ancillary staff member by the physician. Date Posted: 10/16/2009, Date Reviewed/Revised: 08/30/2010 Go to Top • Under limited circumstances, could the term “noncontributory” be used as appropriate documentation to support the review of systems (ROS) and family history sections of the history component of an evaluation and management service (E/M)? It is understood that there are circumstances where the term “noncontributory” may be appropriate documentation when referring to the ROS and/or family history sections of the history component of an E/M service. Under the E&M documentation guidelines, it is noted that, “those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notati
Yes, according to the 1995 E/M Documentation Guidelines, The ROS and/or PFSH section of the history component of an E/M may be recorded by ancillary staff. There must be a notation supplementing or confirming the information that was recorded by the ancillary staff member by the physician. Date Posted: 10/16/2009, Date Revised: 08/30/2010 Go to Top • Under limited circumstances, could the term “noncontributory” be used as appropriate documentation to support the review of systems (ROS) and family history sections of the history component of an evaluation and management service (E/M)? It is understood that there are circumstances where the term “noncontributory” may be appropriate documentation when referring to the ROS and/or family history sections of the history component of an E/M service. Under the E&M documentation guidelines, it is noted that, “those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indica
