E/M Coding Alert - 2017 Issue 4
Reader Question: Navigate "All Others Negative" ROS
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Article Overview
This reader Q&A explains general documentation considerations for review of systems in the context of E/M coding. It discusses how auditors may view standardized EHR phrasing, the role of pertinent systems in the history, and why medical necessity and documentation consistency matter for compliance review. The piece is aimed at coders, auditors, and clinicians who document history elements for evaluation and management services.
Why This Topic Matters
Accurate ROS documentation affects whether E/M history requirements are supported and whether the record will withstand audit scrutiny. Understanding how common shorthand is interpreted can help reduce denials, documentation queries, and compliance risk.
What You Will Learn
- How review-of-systems documentation is considered in E/M history selection.
- Why standardized EHR phrasing can affect audit review.
- What general documentation support is expected when multiple systems are recorded.
- How medical necessity relates to review-of-systems documentation.
Who Should Read This
- Medical coders
- Outpatient auditors
- Physicians and surgeons
- Compliance staff
- Clinical documentation specialists
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