Outpatient Facility Coding Alert - 2001 Issue 3
Reader Question: Review of Symptoms vs. Past Medical History
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Article Overview
This reader question explains a common documentation distinction for evaluation and management coding: separating review of systems from past medical or surgical history. It is aimed at coders, auditors, compliance staff, and clinicians who document histories in emergency or office settings. The article provides a short coding-focused discussion of how to recognize the kind of information that belongs in ROS versus other history elements.
Why This Topic Matters
Accurate differentiation of history elements supports compliant documentation review and avoids misclassification of patient history.
What You Will Learn
- How this article distinguishes review of systems from past medical or surgical history
- What types of documentation are considered current system-based review information
- Why certain history statements should not be counted as ROS
- How the distinction affects documentation review in clinical coding
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Physicians
- Clinical documentation staff
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