Outpatient Facility Coding Alert - 2013 Issue 10
Reader Question: Choose Between 3 ROS Levels
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Article Overview
This reader question article addresses review of systems (ROS) documentation as part of evaluation and management (E/M) history. It is intended for coders, billers, and clinical documentation staff who need a clearer understanding of the broad ROS framework referenced in CPT and CMS documentation rules, including how ROS is categorized and why the level of documentation matters for E/M reporting.
Why This Topic Matters
Understanding ROS level is important because it affects how history is supported within an E/M service and whether certain E/M code selections may be possible based on the documented encounter.
Article Sections
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Question
A reader asks for clarification on the levels of review of systems used in E/M documentation.
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Answer
The response outlines the general ROS framework, references CPT and CMS documentation rules, and discusses how ROS relates to history documentation for E/M services.
What You Will Learn
- How review of systems fits into E/M history documentation
- The general categories of ROS discussed in CPT and CMS guidance
- Why the level of ROS documentation can affect E/M reporting
- The documentation concepts associated with complete and extended ROS
Who Should Read This
- Medical coders
- Medical billers
- Coding educators
- Clinical documentation improvement staff
- Physician office staff
Codes Discussed
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