Say NO to Rein in the Review of Systems

For not a single year, taking history and physical exams out of the calculations for level-based E/M services was on the wish list of CMS and Healthcare leaders. The first year that the office/other outpatient visits (99202-99215) were coded based on medical decision-making (MDM) or time was 2021.   

However, we have noticed that some providers continue to document reviews of 10 or more body systems of each patient. Let’s explore whether this is a problem.   

You should know that excessive review of systems is still a red flag.