AMA CPT® Assistant - 1998 Issue 1 (January)

Documentation Guidelines, Medical Record Documentation (Q&A) (January 1998)

January 1998 page 10d Coding Consultation Documentation Guidelines, Medical Record Documentation (Q&A) If a medical record does not separately list review of systems, but other problems are identified in the history of present illness, can these problems be counted as part of the ROS? AMA Comment Yes, if it is evident the physician asked questions pertaining to that particular body system. The information does not have to be in an area labeled "Review of Systems." Documentation Guidelines, Medical Record Documentation (Q&A). CPT® Assistant. 1998; January 1998 page 10d ...

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