E/M Coding Alert - 2014 Issue 26
Reader Question: Negative Notation Could Be Positive
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Article Overview
This article addresses a reader question about medical record documentation in the review-of-systems portion of patient history. It explains the documentation context, why auditors may scrutinize repetitive charting patterns, and what general considerations matter when determining whether the documented history appears consistent with the presenting problem. The piece is aimed at coders, auditors, and documentation staff who need to judge whether charting supports evaluation and management reporting.
Why This Topic Matters
Review-of-systems documentation is often evaluated during coding audits, and repetitive or sparse charting can raise questions about medical necessity and record consistency. Understanding the documentation context helps practices reduce audit risk and assess whether history support is appropriately recorded.
Article Sections
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Question
Introduces the reader’s documentation concern and the basic context for the discussion.
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Answer
Explains the general documentation and audit considerations related to review-of-systems charting.
What You Will Learn
- How review-of-systems documentation is discussed in a coding and audit context
- Why repetitive documentation patterns can attract auditor attention
- What broad factors are considered when assessing whether a charted review appears consistent with the complaint
- How documentation practices relate to evaluation and management record support
Who Should Read This
- Medical coders
- Auditors
- Physician office staff
- Compliance staff
- Clinical documentation improvement professionals
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