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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Article Overview
This short AMA Coding Consultation Q&A explains a documentation guideline related to medical record history elements and review-of-systems reporting. It is relevant to clinicians, coders, auditors, and documentation specialists who need to understand how narrative chart content is treated when standard section labels are absent.
Why This Topic Matters
Accurate medical record documentation affects evaluation and management history completeness and coding integrity. This article clarifies a documentation concept that can influence how charted information is interpreted during review.
What You Will Learn
- How this documentation guideline addresses history elements in the medical record.
- How narrative charting may be interpreted when a standard section label is not present.
- The general scope of the AMA guidance discussed in the Q&A.
- The relevance of the topic to evaluation and management documentation review.
Who Should Read This
- Coders
- Clinical documentation specialists
- Auditors
- Physicians and other clinicians
- Billing staff
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