The practice of obtaining a broad and thorough assessment of a patient’s health status by conducting a review of systems (ROS) has been taught to medical trainees as an integral part of the history-taking process for decades. In 1995, the ROS was further codified as a required part of a complete medical history in the United States through documentation guidelines for clinical evaluation and management (E/M) by the Centers for Medicare & Medicaid Services (CMS).1 The architects of these guidelines created a framework for E/M reimbursement based on the premise that documentation could function as an accurate proxy for services rendered.
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Hendrickson MA, Melton GB, Pitt MB. The Review of Systems, the Electronic Health Record, and Billing. JAMA. 2019;322(2):115–116. doi:10.1001/jama.2019.5667
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