General Surgery Coding Alert - 2019 Issue 6
Reader Question: Who Can Record a ROS? Find Out
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Article Overview
This article addresses a common office documentation question about who may record a review of systems and what the record should show for E/M support. It is useful for coders, compliance staff, and clinicians who document or audit office notes, and it references CMS documentation guidance as the supporting framework.
Why This Topic Matters
Accurate E/M documentation affects coding support and audit readiness. Understanding the documentation expectations around ROS helps practices align workflow with compliance guidance.
What You Will Learn
- The role of ROS in E/M documentation
- How office documentation may capture ROS information
- What the record should reflect about provider review
- How CMS documentation guidance relates to ROS documentation
Who Should Read This
- Medical coders
- Compliance staff
- Physicians
- Clinical staff
- Practice managers
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