decisionhealth Newsletters, decisionhealth - 2010 Issue 6 (June)
Understanding E/M: Make sure ROS asks for signs and symptoms, not diagnoses
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Article Overview
This article covers documentation guidance for review of systems in evaluation and management (E/M) history, including how forms are structured, what counts toward a complete review, and why diagnosis-based prompts can be problematic. It is intended for coders, auditors, and clinical documentation staff who work with E/M history requirements and Medicare-aligned documentation practices.
Why This Topic Matters
Accurate ROS structure affects whether a history can be counted as complete and can influence audit risk. The article helps readers recognize documentation pitfalls in templates and cloned records so they can better align forms with recognized E/M history standards.
What You Will Learn
- How review of systems is defined in E/M documentation guidance
- Why symptom-focused questions are used instead of diagnosis-based prompts
- How complete ROS documentation is described in Medicare-oriented guidance
- Why copied-forward or cloned histories can create documentation concerns
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation specialists
- Physician office staff
- E/M documentation reviewers
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