Evaluation and Management (February 2001)

February 2001 page 11-end Coding Consultation Evaluation and Management, Comprehensive Level (Q&A) Question How many systems must be reviewed and documented for a comprehensive level history? Also, can the physician indicate that systems are negative? AMA Comment Based on the 1997 Medicare Documentation Guidelines, a comprehensive level evaluation and management service includes performance of a general multi-system examination or a complete examination of a single organ system. A complete review of systems (ROS) inquires about the system(s) directly related to the problem(s) identified in the history of the present illness, plus all additional body systems. Based on the...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This premium article explains a coding consultation focused on evaluation and management documentation requirements for a comprehensive-level history. It is aimed at coders, auditors, and clinicians who need to understand the documentation framework discussed in AMA guidance and how it relates to history and review-of-systems reporting.

Why This Topic Matters

Accurate evaluation and management documentation is central to coding compliance, audit readiness, and consistent recordkeeping. This article helps readers understand the broad documentation standards being discussed in the context of comprehensive-level services.

Article Sections

  1. Coding Consultation

    Introduces the documentation-focused consultation topic and frames the question addressed in the article.

  2. Evaluation and Management, Comprehensive Level (Q&A)

    Presents a question-and-answer discussion of comprehensive-level evaluation and management history documentation and related review-of-systems notation practices.

What You Will Learn

  • The documentation topics discussed for comprehensive-level evaluation and management history
  • How the article frames review-of-systems documentation at a high level
  • The general type of AMA guidance referenced in the discussion
  • How the article approaches physician notation practices in a Q&A format

Who Should Read This

  • Medical coders
  • Coding auditors
  • Compliance professionals
  • Physicians
  • Clinical documentation staff

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