Outpatient Facility Coding Alert - 2009 Issue 9
READER QUESTIONS :Group Same-System ROS Queries Together
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Article Overview
This article addresses a coding question about review of systems (ROS) within evaluation and management documentation. It explains how to think about same-system symptom queries, how that affects ROS level selection, and how the discussion relates to emergency department E/M history elements. It is useful for coders, auditors, and clinicians who document or review E/M notes.
Why This Topic Matters
Correctly identifying ROS level affects E/M history interpretation and supports more consistent documentation review for emergency department services.
Article Sections
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Question
A reader asks about categorizing symptom questions documented during an E/M encounter.
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Answer
The response discusses ROS level concepts and relates them to emergency department E/M history documentation.
What You Will Learn
- How review of systems questions are grouped within a single system
- How ROS level relates to emergency department E/M history documentation
- Why the number of symptom questions does not always equal the number of systems reviewed
- How this topic is relevant to coders and auditors reviewing E/M notes
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Clinical documentation specialists
- Emergency department staff
Codes Discussed
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