Medicare Compliance & Reimbursement - 2010 Issue 2
Follow This FAQ to Ensure ROS Level Success
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Article Overview
This FAQ-style article helps emergency department coders and clinicians understand review of systems (ROS) as part of E/M history documentation. It discusses the general framework for ROS levels, how documentation standards from CPT and CMS may differ, and why payer-specific policy review matters when assessing whether documentation supports a given E/M history level.
Why This Topic Matters
ROS selection can affect whether an ED encounter supports the intended E/M level, so understanding the governing documentation standard is important for accurate coding and consistent payer compliance.
Article Sections
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What Is ROS?
Introduces review of systems as a history element within E/M services and explains its relationship to the presenting problem and other history components.
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What Are Systems?
Summarizes the broad organ-system categories referenced for ROS documentation and how questions are organized within those categories.
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Why Does ROS Matter?
Explains the general importance of ROS level determination in emergency department E/M coding and compares documentation expectations across commonly used standards.
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Careful:
Highlights the need to check payer policy and documentation guidance when determining whether a ROS meets the applicable standard.
What You Will Learn
- How review of systems fits into emergency department E/M history documentation
- The general categories used to organize ROS documentation
- Why payer and documentation standard differences matter for ROS assessment
- How ROS level evaluation relates to ED E/M service selection
- The importance of checking payer-specific ROS expectations
Who Should Read This
- Emergency department coders
- Professional coders
- Clinical documentation staff
- Billing staff
- Physicians and other clinicians documenting E/M services
Codes Discussed
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