ED Coding and Reimbursement Alert

Is "All Other Systems Negative" a ticking time bomb, set to explode your ROS cred?

If you're relying too heavily on the handy phrase "all other systems negative" in documenting a complete Review of Systems (ROS), you could be setting yourself up for an audit feeding frenzy.

The basics: ROS is a crucial element in supporting a 99285 E/M service; CMS E/M Guidelines indicate that documenting pertinent positive and negative findings combined with the statement "all other systems are negative" will be considered a complete Review of Systems. This phrase can be beneficial to allow physicians a shortcut in the documentation process.

Caveat: Physicians should realize the gravity of documenting "all other systems negative", warns Todd Thomas CPC, CCS-P, President of ERcoder, Inc. in Edmond, OK. "All other systems negative" is often interpreted to mean that the physician has performed a review of all fourteen systems, and other than the systems documented individually, the rest of the systems had a negative finding, he adds. "I have participated in audits where the physician's use of 'all others negative' was called into question because of the appearance that it was used on a high percentage of charts regardless of the patient's complaint or whether a complete ROS seemed to be clinically appropriate."

Let Medical Necessity Guide Your Documentation

"To quote the auditor in our most recent experience, 'Due to excessive documentation for minor presenting problems, I have been forced to make a judgment call to identify which E/M elements to score as reasonable and necessary for many of the visits'," Thomas offers.

CMS has addressed the issue of medical necessity in the Medicare Carriers Manual. It states, "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed." In addition to the issue of medical necessity, the accuracy of the statement has been called in to question because of conflicting information in the medical record, the emergency physician documented "All others negative" for the ROS but also documented that they were unable to obtain a complete history due to the patient's condition, says Thomas.

Check out These Payer Policies On AOSN

Payers have become leery of the "All other systems negative" statement, due to a perceived over use and demonstrated inconsistencies in its application, says Thomas. On their website,

Trailblazer Health Services says, "The Centers for Medicare & Medicaid Services has stated that carriers have the right to interpret the guidelines." Trailblazers, which is the Medicare carrier for several states, has at times put forth a position that the notation of "all other systems negative" may not be uniformly accepted, though they went on to say that there would not be a clear and distinct deviation from the 1995 Documentation Guidelines permissible." In addition to Trailblazer, Noridian, Empire, Anthem and HGSA have also at least considered the possibility of not accepting "All other systems negative" for a complete ROS, he adds.

Wisconsin Physician Services (WPS) goes a step further posting the following on their website:

"Due to a recent clarification from CMS, those systems addressed in the ROS must be individually documented. All systems reviewed should be documented, regardless of findings. It is no longer appropriate to just state "all other systems are negative" without specifically listing those systems reviewed."

They did feel they had supporting documentation, but after two weeks of discussion they reversed their position and the statement was removed from their site, Thomas says.

Not All ROS Statements Are Acceptable, Look For These Kinds of Documented Phrases

In addition to overuse, some payers and auditors have demonstrated a concern about vague or ambiguous statements by physicians in an attempt to satisfy the compete ROS requiring. In audits, Thomas adds, payers have been reluctant to give credit for a complete ROS for the following statements:

• "10 point review of systems was completed and is negative unless otherwise stated."
• "Review of systems per HPI otherwise negative."
• "Negative for chest pain, ROS otherwise negative."

None of the above examples specify that all systems or even 10 systems were reviewed. In a recent RAC Monitor article, one of the top 10 audit problems was "poorly documented ROS, including blanket statements like "all systems unremarkable" which many MACs/Part B Carriers do not recognize as legitimate", Thomas warns.

Follow This AOSN Documentation Plan

Based on past experiences with audits and discussions with payers, Thomas recommends that ED physicians use the following documentation policy to ensure that ROS statements contain specific language to qualify as a complete ROS:

If the physician elects to use an inclusive negative statement such as "all other systems negative", the language must include one of the following:

• "all systems"
• "10 systems" (or more than 10)
• "complete ROS"

Consider this example from Thomas showing how a well worded ROS statement can satisfy the documentation requirement

HPI: Patient presents with a suspected spider bite on her right distal forearm. She noticed redness in the area about a week ago, which has progressively spread and worsened since then. She denies any previous skin infections of this nature and no trauma or contact with other skin infections during this period. She also denies fever and reports no weakness, numbness or tingling in the area. No relieving or exacerbating factors were reported.

ROS: A ten system ROS was complete and negative except as noted above.