ED Coding & Reimbursement Alert - 2011 Issue 7
Reader Question: 'Complete' ROS Considers All Systems
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Article Overview
This reader Q&A addresses documentation expectations for a complete review of systems in evaluation and management reporting. It is useful for physicians, coders, and billing staff who need to understand the general documentation standards tied to new and established patient office visits and consultation services. The article discusses CMS guidance, documentation approaches, and how these requirements relate to higher-level E/M encounters.
Why This Topic Matters
Accurate ROS documentation can affect whether an encounter supports a higher-level E/M service. This article helps readers understand the general documentation framework so they can evaluate whether a note is likely to meet the expected history requirements.
Article Sections
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Question
The reader asks about what qualifies as a complete review of systems for higher-level E/M documentation.
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Answer
The response discusses CMS guidance, documentation approaches for a complete review of systems, and the relationship between that documentation and certain office and consultation visit levels.
What You Will Learn
- How the article frames a complete review of systems in E/M documentation
- What general documentation approaches are discussed for supporting a complete ROS
- Which types of office and consultation visits are referenced in connection with ROS documentation
- How CMS guidance is described in relation to review of systems documentation
Who Should Read This
- Physicians
- Surgeons
- Medical coders
- Billing staff
- Compliance staff
Codes Discussed
Code Ranges Discussed
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