Part B Insider - 2018 Issue 8
You Be the Coder: Avoid '10 Negative ROS' Pitfall
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Article Overview
This educational coding Q&A addresses a common evaluation and management documentation question involving review of systems (ROS) notation in surgical notes. It is aimed at coders and compliance-minded clinicians who need to understand how ROS documentation is evaluated under the 1995 and 1997 E/M Documentation Guidelines and why some shorthand phrasing may not support the intended level of documentation.
Why This Topic Matters
Accurate ROS documentation affects E/M leveling, audit readiness, and compliance. The article helps readers recognize documentation patterns that may be misunderstood and encourages more complete, defensible charting.
What You Will Learn
- How review-of-systems documentation is assessed for E/M purposes
- Why abbreviated ROS phrasing can be misunderstood
- What types of documentation support a complete ROS
- How documentation habits can affect coding accuracy and compliance
Who Should Read This
- Medical coders
- Coding auditors
- Physicians and surgeons
- Compliance staff
- Clinical documentation improvement staff
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