General Surgery Coding Alert - 2006 Issue 2
You Be the Coder: Do I Need a Complete ROS for 99285?
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Article Overview
This article reviews an emergency department coding question involving documentation support for a high-level evaluation and management service. It explains the general categories of history, examination, and medical decision-making that are considered, along with the role of review of systems and related documentation standards. The piece is useful for coders, auditors, and clinicians who document ED encounters and want to understand how payer review may differ from chart-level assumptions.
Why This Topic Matters
Emergency department E/M coding depends on complete, internally consistent documentation. Understanding how history components and documentation guidelines affect code selection helps reduce claim denials and supports more accurate chart review.
What You Will Learn
- How emergency department E/M documentation is evaluated at a high level
- How history components are discussed in relation to level-five services
- How review of systems documentation is considered in documentation review
- Why payer review may differ from initial coding assumptions
- What documentation support may be needed when patient condition limits a complete review
Who Should Read This
- Medical coders
- Coding auditors
- Emergency department clinicians
- Compliance staff
- Billing staff
Codes Discussed
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