Outpatient Facility Coding Alert - 2019 Issue 7
Reader Question: Review the Answer to This ROS Recording Question
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Article Overview
This article addresses a reader question about review of systems documentation in an office setting and explains the general documentation expectations tied to evaluation and management coding. It is relevant for coders, auditors, compliance staff, and clinical documentation teams who need to understand how ROS information is captured and confirmed in the medical record. The discussion references CMS documentation guidance and focuses on the broader documentation requirements rather than on code selection details.
Why This Topic Matters
Proper ROS documentation can affect evaluation and management level support, compliance review, and audit readiness. The article helps readers understand the documentation relationship between staff-recorded information and provider review.
What You Will Learn
- Who may record review of systems information in an office practice
- How provider review of recorded ROS information fits into documentation requirements
- How CMS documentation guidance relates to ROS documentation for evaluation and management services
- What documentation elements auditors and coders look for in the record
Who Should Read This
- Medical coders
- Compliance auditors
- Clinical documentation staff
- Physicians and other providers
- Practice managers
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