For me, it is easier to educate the physicans on the documentation than to argue with an auditor
If you go to Texas Trailblazer website and click on the tab on the left for "Policies". Has all the letters and postings From the Desk of the Medical Director
http://www.trailblazerhealth.com/Tools/Notices.aspx?ACTION=search&DomainID=1
Three Magic Words? A Frowning Medicare Contractor’s Perspective
(1/22/2010)
“In order to have complete review of systems, they say three magic words: all others negative.” —Nancy M. Enos (From the January ACP Internist, copyright © 2010 by the American College of Physicians)
The January 2, 2010, edition of ACP Internist contained an article by Stacey Butterfield, titled “Clinicians Crucial to Avoiding Coding Errors.”
The ACP Internist article is about coding Evaluation and Management (E/M) services. The article is informational, well-written and worthy of the few minutes its reading requires.
However, it contains some information about which TrailBlazer Health Enterprises® wishes to caution you. The purpose of this article is to give praise where praise is due (and in doing so to reiterate the article’s useful information) and to warn you of some items in the article that TrailBlazer SM finds troublesome.
Here are some of the commendable points made in the ACP Internist article:
•It recommends care by coders and billers to understand the clinical services rendered to avoid making senseless, sometimes unknowing, and always costly coding errors.
•It urges coding involvement by clinicians by accurately communicating, via medical record documentation, the true nature of their medical services.
•It mentions the importance of medical necessity in coding E/M services.
•It lists common coding mistakes, including abuse and misuse of modifiers 24 and 25.
•It points out several caveats with documenting high-level initial E/M services that require three of three key components as well as both comprehensive history and comprehensive physical.
•It suggests caution in relying solely on electronic E/M code selection.
•It points out that routine annual physicals are not covered under the Medicare benefit, and that any element of a routine physical must be reported separately (separate from covered E/M services) because the expense of these non-covered services is the patient’s responsibility.
The article’s first controversial comment regards coding the complete Review of Systems. The author quotes consultant Nancy M. Enos about using the “all others negative” notation as the basis for deeming a Review of Systems complete. The author further adds “many Medicare carriers frown on the liberal use of the phrase ‘all others negative’ although it is allowed under the CMS 1997 documentation guidelines.”
Be aware that TrailBlazer is one of the frowning Medicare contractors. We disagree that the CMS 1997 E/M Guidelines sanction the “three magic words” as adequate documentation of a complete Review of Systems.
Having reviewed the CMS E/M guidelines, discussed this issue with CMS’ central office, and by placing the guidelines’ statement about “all others negative” in context with all other CMS payment and documentation rules, TrailBlazer has concluded the following about documentation and coding a complete Review of Systems:
•Symptomatic systems must be separately documented and may not be documented simply as “positive” or “negative."
•Systems related to the presenting complaint/problem must be separately documented and may not be documented simply as “positive” or “negative.”
•Asymptomatic systems not related to the presenting complaint/problem may be documented simply as “negative.”
•A complete Review of Systems requires review of at least 10 systems – positive and/or negative.
•The statement “all others are negative” is insufficient documentation of a complete Review of Systems for which at least 10 systems are not identified as having been reviewed.
The second issue of concern in this ACP Internist article regards recommending the use of CPT code 99214 to report an encounter solely for evaluation and management of an uncomplicated new illness without systemic involvement, such as acute otitis media. The author states that making the diagnosis of otitis media meets the standard required of moderate medical decision-making; therefore, with a good history of the present illness, reporting such a service using CPT code 99214 is appropriate. TrailBlazer does not share the author’s opinion on this issue. First, from a medical decision-making point of view, evaluation and management of an uncomplicated acute illness without systemic involvement does not ordinarily involve moderate medical decision-making (as judged by the E/M coding guidelines). Secondly, TrailBlazer would generally not find medical necessity for the work associated with such a service.
E/M services are inherently complex, difficult to codify and are prone to numerous coding errors. Code them carefully and thoughtfully considering both the work documented and the medical need of the patient.
Minimizing those errors is our shared responsibility. For more information about documenting and reporting E/M services to Medicare, TrailBlazer encourages you to browse our E/M Services Web page often.
(Reference: From the Desk of the Medical Director)
