ROS & PFSH Information & Guidelines
When describing any new ROS and/or PFSH information or making a note that there was no change in the information, providers should list the date and location of the earlier ROS and/or PFSH in their notes for that date of service. To document the provider reviewed the information, a notation supplementing or confirming the information recorded by others per the CMS’s Evaluation and Management Documentation Guidelines should be included.
Remember: Although rerecording certain elements is no longer necessary, providers will need to provide evidence the information was reviewed, make any necessary updates and indicate the work in the patient’s medical record for that date of service.
The key documentation guidelines practitioners need to remember when reviewing and updating the ROS and PFSH include:
- Describe any new ROS and/or PFSH information, or note the information has not changed; and
- Note the date and location of the earlier ROS and/or PFSH.
The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document the physician reviewed the information, a notation supplementing or confirming the information recorded by others must be made.
Things to Keep in Mind
Keep in mind, the CMS has not eliminated the requirement to document any history, exam and/or medical decision making, but rather, it is working in response to feedback on eliminating unnecessary and outdated requirements associated with payment for the levels of E/M visits. The goal is for providers to document what is clinically relevant and medically necessary to support the service.
Although these guidelines are set by the CMS in policymaking, whether third-party payers will implement the same policy remains unknown, so practices must verify each payer’s billing guidelines—especially given that most Medicare patients have a secondary payer. Practices should continue applying best practices in coding and billing claims to minimize delays or denials.
The AMA/Current Procedural Terminology (CPT) Editorial Panel is currently working to revise the E/M code set by 2020 or 2021, which would help establish uniformity among payers. The ACR is involved in the meetings and monitoring the revision of each section of the E/M coding guidelines.
As always, providers should continue documenting substantial information in the medical record for clinical, legal and other policy purposes, such as risk adjustment, quality reporting, productivity measures and potentially for other payers. The ACR Practice Management Department continues to provide coding education for physician practices on state and national levels in an effort to assist members and their staff to understand the changes, get everyone trained and maintain the practice workflow for efficiency.
