Medicare Compliance & Reimbursement - 2005 Issue 22
Documentation: Keep An Eye Out For These Clues In Review Of Systems Documentation
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Article Overview
This article discusses how to read review of systems documentation more accurately in the context of evaluation and management coding. It focuses on common documentation issues, such as distinguishing body systems, avoiding confusion with history information, recognizing overlapping symptoms, and understanding when apparently unrelated questions may affect ROS counting. The guidance is aimed at helping coding and auditing staff evaluate physician documentation more consistently.
Why This Topic Matters
Review of systems documentation can influence the level of service supported by the record. Understanding common documentation traps helps coders and auditors assess whether ROS entries are being interpreted consistently and appropriately.
Article Sections
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9 tips to capture every relevant system
Introduces practical considerations for reviewing ROS documentation and identifying systems that may be represented in physician notes.
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Don't Credit One Statement To Many Systems
Explains that some symptoms or questions may seem relevant to more than one body system and discusses the need for careful system assignment when reviewing documentation.
What You Will Learn
- How review of systems documentation is commonly interpreted by coders
- Why distinguishing body systems in ROS notes matters
- How to recognize documentation that may belong to history rather than ROS
- How overlapping symptoms and broad questions can affect documentation review
- Why unrelated or unnecessary ROS content can create compliance concerns
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physician documentation reviewers
- Revenue cycle staff
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