ED Coding & Reimbursement Alert - 2016 Issue 12
Reader Question: Use This Advice to Navigate 'Negative' E/M Notes
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Article Overview
This reader Q&A explains a documentation issue affecting evaluation and management (E/M) chart review, focusing on how review of systems (ROS) statements are documented in the electronic medical record and how auditors may view patterns of negative responses. It is aimed at physicians, coders, auditors, and compliance staff who review medical necessity and history documentation. The article covers general guidance on complete ROS documentation, the relationship between ROS and medical necessity, and common audit concerns with repetitive EMR wording.
Why This Topic Matters
Accurate ROS documentation can affect whether E/M history is considered complete and whether a chart supports the service billed. Understanding how auditors assess repetitive or unsupported documentation helps reduce compliance risk.
What You Will Learn
- How review of systems documentation is evaluated in E/M chart review
- Why medical necessity matters when documenting ROS
- What audit concerns can arise from repetitive EMR documentation patterns
- How a complete ROS is generally recognized in documentation review
Who Should Read This
- Physicians
- Medical coders
- Medical auditors
- Compliance staff
- Billing staff
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