Medicare Compliance & Reimbursement - 2018 Issue 8
Reader Question: Add up Negatives to Complete ROS Equation
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Article Overview
This reader Q&A addresses review of systems documentation in the context of evaluation and management (E/M) coding. It focuses on how documentation is interpreted under the 1995 and 1997 E/M Documentation Guidelines, what kinds of ROS statements are considered complete, and why certain shorthand phrasing can create audit or selection problems. The article is aimed at coders and clinicians who document E/M services and want to understand the documentation standard at a high level.
Why This Topic Matters
Review of systems documentation can affect E/M level selection and audit defensibility. Understanding the documentation standard helps avoid overreporting or misinterpreting abbreviated ROS statements in the medical record.
What You Will Learn
- How review of systems documentation is evaluated for E/M purposes
- Why abbreviated negative ROS statements may be insufficient
- How the 1995 and 1997 E/M Documentation Guidelines relate to ROS completeness
- What types of ROS documentation patterns are commonly confused
- General documentation practices that support complete ROS reporting
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Clinical documentation staff
- E/M billing specialists
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