Primary Care Coding Alert

Question: I lose audit points when I use the term "noncontributory" for any portion of ROS. What should I recommend the family physician (FP) 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 FP considered the review of system (ROS) element unimportant or nonapplicable. Therefore, she didn't ask the patient about the item.
 
Legally, your FP should replace "noncontributory" with "no pertinent positive or negative findings." But no physician will write that out.
 
Better method: You should encourage your FP to use a statement that suggests she asked the patient about the bullet. For instance, a note stating "none reported" indicates the item mattered.