Outpatient Facility Coding Alert - 2011 Issue 6
Evaluation and Management: Don't Let ROS Errors Cost You Level 4 or 5 E/M Pay
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Article Overview
This article explains review-of-systems documentation within evaluation and management coding and why it matters for surgeon office visits. It is aimed at coders, surgeons, and practice staff who document or audit E/M histories. The article covers the broad ROS categories, the systems commonly counted, examples of documentation patterns, and who may record ROS information for the encounter.
Why This Topic Matters
ROS documentation can influence whether a visit supports higher or lower E/M history levels, which affects coding accuracy and reimbursement. The article helps readers recognize common documentation gaps and understand the general documentation expectations discussed by the source.
Article Sections
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Differentiate ROS Levels
Introduces the main ROS categories used in E/M history assessment and explains how they relate to visit level selection in general terms.
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Learn the Systems You Will Be Counting
Reviews the body systems that may be considered when documenting ROS and includes a broad example of how systems may be documented during an encounter.
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Determine Who Can Record the ROS
Discusses who may document ROS information and the role of patient- or staff-completed forms in the process.
What You Will Learn
- The role of ROS within E/M history documentation
- How ROS is categorized at a high level
- Which broad body systems may be counted in ROS documentation
- Why complete documentation of reviewed systems matters
- Who may help capture ROS information for an encounter
Who Should Read This
- Medical coders
- Coding auditors
- Surgeons
- Physician assistants
- Nurse practitioners
- Medical office staff
Codes Discussed
Code Ranges Discussed
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