decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Appendix C - 1995 EM Guidelines / Review of systems or ROS
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Article Overview
This premium article covers the review of systems (ROS) element in the 1995 evaluation and management guidelines. It is intended for coders, auditors, and clinicians who need a clear understanding of how ROS is organized, what body systems are included, and the broad documentation expectations associated with problem-pertinent, expanded, and complete reviews.
Why This Topic Matters
ROS documentation affects evaluation and management record completeness and level-of-service support. Understanding the scope of ROS helps users evaluate whether charting aligns with the guideline framework referenced in the article.
Article Sections
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Review of systems overview
Defines the ROS element and identifies the broad categories of body systems considered in the 1995 guideline framework.
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Problem-pertinent ROS
Describes the limited ROS approach tied to the problem being evaluated and the general documentation expectations for that level.
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Expanded ROS
Summarizes the broader ROS approach that covers the problem-related system plus additional systems and notes the general documentation scope.
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Complete ROS
Outlines the most extensive ROS category and the general requirement for reviewing multiple organ systems with documentation expectations.
What You Will Learn
- How the review of systems is defined in the 1995 EM guideline context
- Which broad body systems are included in ROS
- How ROS is categorized at a high level
- What general documentation scope is associated with each ROS category
Who Should Read This
- Medical coders
- Coding auditors
- Physicians and other clinicians
- Compliance staff
- Revenue cycle professionals
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