ED Coding and Reimbursement Alert

Question: I know that the provider can state -all other systems reviewed and negative or are noncontributory- and receive credit for a complete review of systems (ROS), but does this rule appear in any guidelines? And can we accept -noncontributory- for a complete past family social history (PFSH)?


Michigan Subscriber

 
Answer: To be safe under audit, you shouldn't accept the phrase -noncontributory- for either ROS or PFSH. Upon seeing this phrase in the documentation, the first thing an auditor will do is ask you to prove that -non-contributory- doesn't mean that the doctor failed to ask because he didn't deem the information relevant. The word -unremarkable- may push you into the same tough spot, so tell your physicians to avoid that one as well. Instead, your physicians should use -negative.-

In the 1995 documentation guidelines, in the section describing a complete ROS, you-ll find the following statement: -At least 10 organ systems must be reviewed. Those systems with positive or pertinent negatives must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible.-

Before checking the -all other systems negative- box or making a statement to that effect, the physician is required by the documentation guidelines to indicate at least one pertinent positive or negative for reference. Of note, some carriers are disputing this allowance even though they are in the 1995 documentation guidelines.