Medicare Compliance & Reimbursement

Ensure that your MAC accepts this commonly-documented phrase before you see your claims downcoded.

Background: The E/M documentation guidelines simply say, "Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible." If the physician indicates positive or negative for at least one system and checks the "all others negative" box, then based on these standards, he has documented a complete ROS.

The problem: Individual carriers began to reevaluate the use of the "all others negative" statement over the years, and some payers decided they didn't want to pay for systems that weren't individually documented.

For example: In 2008, Trailblazer Health Enterprises (a Part B payer in four states) removed the phrase and check box for "all others negative" from the ROS section of its Coding Pocket Reference. In April 2011, Trailblazer then issued a Bulletin that noted, "In regard to ROS there is confusion in the provider community about what documentation is required. All positive systems reviewed must be documented to be considered for coding".

"All pertinent negative systems reviewed must also be documented to be considered for coding. Asymptomatic and/or non-pertinent systems may be documented in a single 'negative' statement if those systems are identified " (emphasis added).

What this means: If an auditor who works under the Trailblazer guidelines reviews your records and finds that you documented a positive for one system along with an "all other negative" statement without identification of which systems were reviewed and found to be negative, your ROS could be bumped down from "comprehensive" to "expanded problem-focused." This, in turn, could cause a 99204 (Office or other outpatient visit for the evaluation and management of a new patient), which pays about $158, to be downcoded a 99202, which Medicare only pays at about $71. This $87.00 per-visit potential mistake could be very costly for your practice.

Hidden trap: While the decision about ROS is ultimately the physician's, he shouldn't consider checking the "all others negative" box a complete ROS when he hasn't evaluated any other systems. Without documentation of positive or negative responses to at least one system, the "all others negative" statement has no value.

You can also have a problem if a physician has a consistent pattern of checking the "all others negative" box with no variation in the ROS documentation. In the end, the auditors may be uncomfortable if all the charts look the same, particularly if they all have the ROS box checked.

When deciding whether to ask the physician about the ROS documentation, check to see that the number of systems makes sense with the patient's problem. If a physician is always checking the "all others negative" box to imply a complete ROS -- even if he documents individual review of two additional systems -- make sure that the presenting problems warrant review of 10 or more systems.

If not, and the physician has succumbed to checking the "all others negative" box as a default, you could be asking for trouble with auditors. If record upon record shows a complete ROS that is clinically unnecessary, an auditor could suspect that you're using the documentation shortcut as a way to beef up your evaluation and management levels.

Check with your MACs to determine whether they accept "all others negative" -- but urge your physicians to document each body system that they evaluate in their records.