Review of systems key to reporting top visit, consult codes

Why This Topic Matters

Accurate review of systems documentation can affect whether a visit supports a lower or higher level of evaluation and management coding. The article helps readers understand the documentation framework used for office visits and consultations and how those requirements are interpreted in practice.

Article Sections

1. Review of systems and history levels

   Introduces how review of systems documentation relates to history level and office visit or consultation coding. Summarizes the relationship between CPT and Medicare approaches.

2. What is the Review of Systems?

   Defines the purpose of the review of systems and distinguishes it from other parts of the patient record and encounter. Discusses its role in documenting symptoms and supporting clinical assessment.

3. It's not the exam

   Explains common confusion between review of systems, the physical examination, and past medical history. Includes general comments from a coding consultant about the difference between questioning and examination.

4. Documentation tip: Hand out a questionnaire

   Describes a documentation workflow using patient questionnaires and staff assistance. Notes limits on which history components may be obtained by ancillary personnel.

5. Review of Systems Elements

   Lists the broad body-system categories used in review of systems documentation. Provides the standard elements referenced in the article.