E/M Coding Alert - 2019 Issue 8
E/M Coding: Test Your ROS Smarts With This Q & A
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Article Overview
This quiz-style article explains the role of review of systems documentation in evaluation and management coding. It covers the general purpose of ROS in patient assessment, the broad ROS system categories recognized in CPT guidance, the major ROS review levels, and documentation principles that affect whether a review can be counted. It is useful for coders, auditors, and clinical documentation staff who need a practical refresher on ROS-related E/M history support.
Why This Topic Matters
ROS documentation can influence the level of history supported for E/M services, so understanding what belongs in ROS and how it is summarized helps reduce documentation errors and coding inconsistencies.
Article Sections
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Question 1: Why Is An ROS Needed?
Explains the general purpose of review of systems in patient assessment and its relationship to overall evaluation and management documentation.
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Question 2: What Are the ROS Levels, And How Do They Contribute to Code Choice?
Summarizes the broad ROS system categories and the standard ROS review levels, then connects those concepts to E/M history support.
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Question 3: How Should You Document the ROS?
Describes documentation expectations for review of systems and distinguishes ROS content from other parts of the medical record.
What You Will Learn
- The general purpose of review of systems in E/M documentation
- How ROS scope is categorized at a high level in CPT guidance
- How ROS review levels relate to history support for E/M services
- What broad types of documentation help show that a review occurred
- How ROS content is distinguished from other medical history elements
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Clinical documentation specialists
- Physician practices
Codes Discussed
Code Ranges Discussed
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