Otolaryngology Coding Alert

Question: I lose audit points when I use the term "noncontributory" for any portion of ROS. What should I recommend the otolaryngologist document instead?


North Carolina Subscriber

Answer: Auditors don't count "noncontributory" because they interpret the term to mean the bullet didn't matter. The documentation indicates that the otolaryngologist considered the review of system (ROS) element unimportant or nonapplicable. Therefore, she didn't ask the patient about the item.

Legally, your otolaryngologist should replace "noncontributory" with "No pertinent positive or negative findings." But, no physician will write that out.

Better method: You should encourage your otolaryngologist to use a statement that suggests she asked the patient about the bullet. For instance, a note stating "None reported" indicates the item mattered. Other acceptable comments include "WNL" (within normal limits) and "Reviewed nonapplicable."