Part B Insider - 2005 Issue 9
READER QUESTIONS: Use 'All Others Negative' Wisely
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Article Overview
This reader question and answer addresses documentation expectations for review-of-systems entries in emergency department evaluation and management charting. It explains why the topic matters for audit readiness, medical record support, and level selection, and it is aimed at coders, billers, and clinicians who document history components.
Why This Topic Matters
Documentation language in templates can affect how an auditor interprets the record and whether history elements are supported. This makes the article relevant to practices that rely on standardized E/M templates and want to understand audit risk tied to review-of-systems notation.
What You Will Learn
- How template-based review-of-systems wording may be interpreted during audit review
- Why documentation support matters for emergency department evaluation and management history elements
- What kinds of charting practices are discussed in relation to audit risk and level selection
- How this documentation issue may affect coders, billers, and clinicians using standardized templates
Who Should Read This
- Medical coders
- Billers
- Emergency department clinicians
- Practice managers
- Compliance staff
Codes Discussed
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