ED Coding and Reimbursement Alert

See this advice on using "Non-contributory" to document a ROS of past, family, social history.

ED coders frequently wrestle with whether the documented phrase "non-contributory" for a history element satisfies the documentation requirements. The good news is help is here; read on for advice on solving this conundrum:

The challenge: Does "non-contributory" indicate that the physician inquired about those elements and there was nothing about the response that contributed to the current presentation, or does it mean instead that inquiring about those systems would not be contributory to this presentation? The first might be ok to count towards the E/M level assigned because the work was performed; the second would not.

Multiple inquiries over the years indicate that physicians have used the phrase both ways. And because of the differences in the uses, there are many coders and auditors that do not count it when scoring the E/M code, says Todd Thomas, CPC, CCS-P, President of ERcoder, Inc. in Edmond, OK.

Review Your Carrier's Stance

Many carriers have documented policies against the phrases "non-contributory" or "non-pertinent." Thomas offers the following examples:

• "It is important to note that for PFSH, a real social and/or family history must be documented."
• "Non-contributory" according to many carriers is not considered appropriate documentation."
• "When Past, Family and/or Social History documentation has the terms "Non-contributory" or negative, it leaves open to interpretation whether that aspect of the history was performed. Appropriate documentation of the social or family history information, should ideally include components such as alcohol consumption, smoking history, occupation, or familial hereditary conditions."
• Recent chart reviews have included "Past medical history is non-contributory" or "Social history is non-contributory" in the medical record. Such documentation does not clearly indicate the provider had actually addressed the issues. It should be clear that the PFSH was discussed with the patient. To use the term "non-contributory" alone leaves open to question whether the social or family history was addressed."

What to do: The best practice would be for physicians to document the patient's responses to the questions that were asked, Thomas advises.

Crack Review of Systems Documentation

CMS guidelines indicate that documenting pertinent positive and negative findings combined with the statement "all others systems negative" will be considered a complete Review of Systems. However, "all other systems negative" states that the physician has performed a very complete inventory of the patient's body systems.

Many payers have expressed concern about what seems to be excessive use of the "all other systems negative" documentation for a high percentage of visits, especially in cases where a complete ROS did not seem clinically appropriate for the presenting problem, Thomas adds.

Payers question the medical necessity when they encounter a perceived over use of "all other systems negative" during an audit, and at times have expressed concern that the physician may be performing a complete ROS for patients when the chief complaint and presenting problem may not represent a complex presentation.

Heed These Recent Audit Results

Thomas recounts his experience in a recent Medicare audit where the physician's use of "all other systems negative" was called into question because of excessive use and the appearance that it was used on a high percentage of charts, regardless of the patient's complaint or whether a complete ROS seemed to be clinically appropriate.

The final outcome of that audit is pending the physicians' testimony regarding the medical necessity of the complete ROS for the charts in question, all of which were for services rendered in excess of five years ago, says Thomas.

CMS has addressed the issue of medical necessity in section 15501 of the Medicare Carriers Manual (30.3.1 of the internet only manual).

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported."

In a second audit, the physician performing the audit for the payer elected to disregard the "all other systems negative" statement on all of the charts because it was impossible to determine when it was and was not accurately applied, says Thomas. As a result, many of the 99285 charts were down coded due to the lack of a complete ROS without using the "all others negative" statement. When the phrase is used in 100 percent of charts under review, an auditor begins to question the credibility of its appropriate application, he adds.

Watch Your ROS Statements and Systems Numbers Tally

In other similar audits, payers have been reluctant to allow a complete ROS when physicians have taken some liberty with the ROS statement. There have been charts where it appeared that the intent of the physician documentation was to indicate a complete ROS was performed, but the language used in the chart was too vague to be able to know for sure. For instance, payers rejected incomplete notes like "10 point review of systems was completed and is negative unless otherwise stated", "Review of systems per HPI otherwise negative", "Negative for chest pain, ROS otherwise negative". None of these examples specify that all systems or even 10 systems were reviewed. And none of these were allowed by the auditors, Thomas says.

Thomas reports seeing a significant number of ED charts where the physician has documented something along the lines of, "Ten-point review of systems is negative except for that mentioned in the HPI." The ten-point review of systems is problematic because a ROS may have included an inquiry about 10 points but not necessarily 10 systems, he explains.

For example: "No nausea, no vomiting, no diarrhea, no abdominal pain, no shortness of breath, no wheezing, no coughing, no chest pain, no rashes, no fever". That's a 10 point review but only 5 systems.

ROS tip: When a complete ROS has been performed, the best practice is to use the CMS language and document pertinent positive and negative findings combined with the statement "all other systems negative".

From the coder's perspective, the "all other systems negative" statement only comes into play for charts that would otherwise support being coded 99285. For the lower level ED E/M codes, the ROS requirements are pretty simple (2 systems will support 99284 and 99282-99283 only need 1 system) so documenting "all other systems negative" to satisfy the coding requirements is only necessary on the highest acuity cases.

"If the physician has performed a complete ROS, it is perfectly acceptable for them to use all 'other systems negative' as part of their documentation. However, if all systems have not been reviewed simply document those systems that were reviewed", Thomas advises.