ED Coding & Reimbursement Alert - 2014 Issue 27
Find Positive Answers for 'All Others Negative'
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Article Overview
This article discusses documentation practices for the review of systems (ROS) in evaluation and management history-taking when a physician uses an “all others negative” notation. It is aimed at coders, auditors, and compliance staff who need to judge whether ROS documentation appears complete, clinically plausible, and consistent across records. The guidance focuses on general documentation expectations, practice-policy considerations, and audit risk related to repetitive charting patterns.
Why This Topic Matters
ROS documentation affects the apparent completeness of a patient history and can influence audit review of evaluation and management records. Understanding when the notation may be acceptable versus when additional specificity may be needed helps reduce scrutiny and supports more consistent chart review.
What You Will Learn
- How ROS documentation is evaluated when a chart uses an “all others negative” statement.
- Why repetitive documentation patterns can attract audit attention.
- Why practice policies may help standardize ROS charting expectations.
- How ROS completeness is considered in relation to the patient’s presenting problem.
Who Should Read This
- Medical coders
- Audit and compliance professionals
- Clinical documentation improvement staff
- Physicians and practice managers
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