Children’s of MN adopts coding and documentation guidelines from the AMA. We do not typically follow CMS (Medicare based) rules because Children’s is not a Medicare-based facility.

Review of Systems (ROS) and Physical Exam Documentation recommendations:

• The coding guideline changed in 2021 for office/outpatient documentation and in 2023 for inpatient/observation/ED documentation.
• Evaluation and Management levels of service now only require a medically appropriate Review of Systems (ROS) and physical examination.
• These are no longer required elements for coding reviews for a level of service, as levels are determined on medical decision making.
• Per the AMA guidelines, these components are left to the “provider’s discretion for what is medically relevant on the date of service and documented as such.”
• Includes Office/Outpatient, Inpatient/Observation, Emergency Department, and Consultation levels of service.
• Preventive services, such as Well Child visits, continue to require a comprehensive history and exam to fulfill EPSDT requirements.
• There is no longer a need to include statements such as:
  • A 10-point review of systems was conducted and negative aside from as outlined above.
  • Adding a comprehensive list of systems review or physical exam findings.

For further information on these revisions review the link to the AMA guidelines (the History/Exam information is sound on page 6): Evaluation and Management (E/M) Services Guidelines.