General Surgery Coding Alert - 2017 Issue 3
Reader Question: Learn How Often to Update ROS
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Article Overview
This reader Q&A explains general documentation expectations for review of systems (ROS) in evaluation and management (E/M) records. It is aimed at medical coders, billers, auditors, and clinicians who need to understand how ROS documentation is kept current across visits and over time. The article discusses broad guidance on update frequency, use of prior documentation, and the role of medical necessity in maintaining documentation currency.
Why This Topic Matters
ROS documentation is a core part of E/M record support, so understanding how it is maintained helps practices keep records current and consistent for compliance and auditing purposes.
What You Will Learn
- How ROS documentation is discussed in the context of E/M services
- How prior ROS information may be referenced in later encounters
- The role of ongoing documentation updates in maintaining current records
- How medical necessity relates to the timing of ROS updates
Who Should Read This
- Medical coders
- Medical billers
- Auditors
- Physicians
- Clinical documentation staff
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