E/M Coding Alert - 2017 Issue 10
ROS FAQs: Settle Systems Level Before Choosing E/M Code
Subscribe or sign in to view the full article.
Article Overview
This FAQ-style article covers the role of review of systems (ROS) in physician documentation and evaluation and management (E/M) coding. It explains the general ROS levels, how ROS fits within the history portion of a note, and why accurate system review documentation matters for new and established patient visits. The piece is aimed at coders, auditors, and clinical documentation staff working with surgical and office-based E/M records.
Why This Topic Matters
Accurate ROS documentation affects whether the history portion of an encounter supports the intended E/M level. Understanding the general documentation expectations can help coding and clinical staff evaluate notes consistently and reduce avoidable errors.
Article Sections
-
Define ROS for Starters
Introduces review of systems as part of the history portion of a note and outlines the general body systems involved. It also discusses the documentation purpose of ROS in clinical assessment.
-
Know the ROS Choices
Describes the general ROS levels and the documentation scope associated with each level. The section presents ROS as a documentation concept used in E/M history review.
-
Understand ROS's Place in E/M Code System
Explains how ROS relates to E/M coding for new and established patient services. It discusses the broader relationship between history documentation and E/M level selection.
What You Will Learn
- What review of systems means in the context of the medical record
- How ROS is categorized into different documentation levels
- How ROS relates to evaluation and management documentation
- Why ROS documentation can affect E/M code selection
- Which types of encounter documentation are commonly reviewed for ROS support
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation specialists
- Physician office staff
- Surgical practice administrators
Codes Discussed
Code Ranges Discussed
Subscribe or sign in to view the full article.


Quick, Current, Complete - www.findacode.com