tci Outpatient Facility Coding Alert - 2017 Issue 1
You Be the Coder: Just How Many Systems' Review Suffices For a Complete ROS
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Article Overview
This Q&A article addresses a common documentation issue in evaluation and management (E/M) encounters: whether a general "all others negative" statement can support a complete review of systems. It explains the topic at a high level, including the need for at least one documented system response, the importance of physician discretion and medical necessity, and why consistent documentation patterns may draw auditor attention. The piece is useful for coders, auditors, and clinical documentation staff who review ROS documentation for E/M compliance.
Why This Topic Matters
ROS documentation can affect whether an E/M record supports the level of service billed. Understanding the general documentation expectations helps coders and auditors assess completeness and identify records that may need clarification.
Article Sections
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Question
Introduces the documentation scenario and the E/M reporting question being asked.
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Answer
Summarizes the general documentation concept discussed in relation to ROS completeness and provider discretion.
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Caveat
Notes additional concerns about documentation consistency and the relationship between ROS patterns and audit scrutiny.
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Example
Provides a broad clinical illustration of how system review may be considered in an injury-related encounter.
What You Will Learn
- How the article frames ROS completeness in E/M documentation
- Why documentation patterns can matter for audit review
- How medical necessity concerns relate to ROS selection
- What general issues arise when only one system is documented
Who Should Read This
- Medical coders
- E/M auditors
- Clinical documentation improvement staff
- Physician office staff
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