ED Coding and Reimbursement Alert

See this advice on using "Non-contributory" to document a ROS of past, family, social history.ED coders frequently wrestle with whether the documented phrase "non-contributory" for a history element satisfies the documentation requirements. The good news is help is here; read on for advice on solving this conundrum:The challenge: Does "non-contributory" indicate that the physician inquired about those elements and there was nothing about the response that contributed to the current presentation, or does it mean instead that inquiring about those systems would not be contributory to this presentation? The first might be ok to count towards the E/M level assigned because the work was performed; the second would not. Multiple inquiries over the years indicate that physicians have used the phrase both ways. And because of the differences in the uses, there are many coders and auditors that do not count it when scoring the E/M code, says Todd Thomas, [...]