Outpatient Facility Coding Alert - 2010 Issue 23
Reader Questions: For Complete ROS, Check at Least 10 Systems
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Article Overview
This article addresses a common coding question about whether a documented review of systems meets the requirement for a complete ROS in a new-patient office visit. It is useful for physicians, coders, auditors, and documentation specialists who need to understand how system-level findings are counted and how history documentation supports E/M code selection.
Why This Topic Matters
Accurate review-of-systems documentation can affect whether the history component supports a higher-level evaluation and management service. The article also highlights how documentation patterns and summary statements may influence coding review for new-patient visits.
Article Sections
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Question
Presents a documentation scenario involving multiple reported symptoms and asks whether the encounter meets the ROS requirement and how the visit should be coded.
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Answer
Summarizes the review-of-systems assessment for the encounter and discusses the overall implication for visit-level E/M coding.
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Tip
Provides general documentation guidance about counting systems and the role of a broad negative statement in supporting a complete ROS.
What You Will Learn
- How a review of systems is evaluated when multiple symptom groups are documented
- How broad history documentation can influence new-patient E/M service selection
- What kinds of documentation patterns may support a complete ROS determination
- How system counting is handled when the same system is mentioned more than once
Who Should Read This
- Medical coders
- Physicians
- Documentation specialists
- Coding auditors
- Compliance staff
Codes Discussed
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