Title: Competency Assessment: (CU1 M2) E & M Coding - ROS Review
Course: SkillsCom CRS 111 16.1 > Section: Credit Unit 1 Module 2

The goal of this competency is for you to demonstrate your ability to understand and code the Evaluation and Management Review of Systems (ROS) documentation.

1. Review ROS Coding Tips. To complete this competency assessment you will review the following documentation from Dr. Ross concerning his patient, Mr. Thameson.  Dr. Ross coded this encounter as a complete ROS.

"ROS - Patient also experiencing left-sided weakness, especially in the legs which are also cramping at night.  The patient says his skin on his left leg and arm are dryer and itchy.  Patient reports no difficulty breathing or left-sided chest pain.  Patient reports no other painful joints or muscles.  Patient denies any other symptoms such as diarrhea, indigestion, or vomiting."

2. Find a volunteer to role play with you.  Your volunteer will play Dr. Ross.  Your volunteer (Dr. Ross) is of the opinion that he or she is doing everything right when coding the visit.

3. Videotape the role play in which you are having the following discussion with Dr. Ross.

- In the roleplay, respectfully and professionally discuss with Dr. Ross what his coding error was and how to upgrade the documentation so that it meets his desired code, or what else could be done to meet the code that would have been correct of this ROS.
- If you have difficulty with this assessment, contact your Contact Expert.
- As a reminder:
  - Problem Pertinent ROS: Requires review of ONE system related to current problem(s)
  - Extended ROS: Requires review of TWO to NINE systems
  - Complete ROS: Requires review of at least 10 systems
  - Review this E & M Coding Tool.  Note the orange parts of the tool that specifically deal with the History portion of E & M Coding.  This tool may be helpful in determining from the medical documentation which level of coding should be used for this portion of the E & M Coding.  If you have questions, this is a good time to talk to your Content Expert about how to use this tool.

4. Upload your video.