re: noncontributory,negative

lfuller

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re: noncontributory,negative

Can " no pertinent findings" be used instead of "noncontributory" or "negative"? I would like to know how other offices have the providers
document. Thanks.
 

RebeccaWoodward*

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I'm sooooooooooooo glad you posted this question. This is one of my top pet peeves! You're statment should be fine....I prefer "Patient denies any pertinent ___________(i.e. family history) associated with the current problem"

We are transitioning into an EMR and I was very vocal about the "non contributory" statement. This statement is no longer an option. ;)
 

lfuller

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I heard or read somewhere that CMS is also working on eliminating "negative" as an option also. Has anyone else heard that??
 

RebeccaWoodward*

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Is the phrase “reviewed and negative” acceptable as documentation of Past, Family, and Social History (PFSH)?

The phrase "reviewed and negative" by itself would not be acceptable documentation of PFSH, as it does not indicate what was reviewed.

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the History of Present Illness (HPI). A complete PFSH is a review of two or all three areas, depending on the category of E/M services. A complete PFSH requires a review of all three-history areas for services that, by their nature, include a comprehensive assessment or reassessment of the patient.

Resources

CMS 1995 & 1997 E/M Guidelines - http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp
Palmetto GBA E/M Help Center, located in "Articles":
Ohio: http://www.PalmettoGBA.com/boh
West Virginia: http://www.PalmettoGBA.com/bwv
South Carolina: http://www.PalmettoGBA.com/bsc
 
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Stay AWAY from "noncontributory"

I try to train my physicians to specifically state the negatives.
e.g. There is no family history of bleeding disorders or cancer. The patient has had no previous surgeries. The patient does not smoke.

IF the patient has completed the questionnaire in full, the physician CAN state: ROS and PFMS histories as per patient questionnaire, completed by patient and review by me this date. Pertinent positives are: (then they list whatever is positive, whether ROS or history).

As for CMS eliminating "negative" ... think about this for a minute. There is no way they can eliminate the word "negative" or you'd never get a complete ROS (unless someone was REALLLLLY sick and has positive findings in 10+ systems). But I do think that simply stating "ROS negative" won't fly ... which systems were reviewed? (And I always ask my doc, "If all the systems were negative, why is the patient here?" - I work for surgeons, we don't do preventive visits.)

F Tessa Bartels, CPC, CPC-E/M
 
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"all "others" negative

I recently attended a CMS seminar and they mentioned that they are considering doing away with the phrase "all others negative" in the ROS part of the history. (They are warning us now so we can prepare our providers.) According to the speaker it sounds as if the statement "all others negative" may not be accepted in the future but the providers can still perform the ROS and mention positive and NEGATIVE results and obtain a complete ROS. (I was under the impression by the speakers comments that there may be some doubt that the providers are truly reviewing all the systems in the ROS when they state "all others negative".) Just my thoughts. :eek:
As far as how we try and educate our providers - we ask them to document the findings pertinent to why the pt. is being seen and if the medical necessity is there then it would be appropriate to review the "other" systems and indicate the positive, negative responses.
 
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RebeccaWoodward*

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I recently attended a CMS seminar and they mentioned that they are considering doing away with the phrase "all others negative" in the ROS part of the history. (They are warning us now so we can prepare our providers.) According to the speaker it sounds as if the statement "all others negative" may not be accepted in the future but the providers can still perform the ROS and mention positive and NEGATIVE results and obtain a complete ROS. (I was under the impression by the speakers comments that there may be some doubt that the providers are truly reviewing all the systems in the ROS when they state "all others negative".) Just my thoughts. :eek:
As far as how we try and educate our providers - we ask them to document the findings pertinent to why the pt. is being seen and if the medical necessity is there then it would be appropriate to review the "other" systems and indicate the positive, negative responses.
I have heard the same...good point. It will be interesting to see how long it takes to implement this.

Can I say "All other systems reviewed and are negative" when completing the review of systems?

Answer: Unfortunately, the answer to this question is yes and no, depending upon your state's Medicare carrier. This shortcut is indeed contained in both the 1995 and 1997 E/M guidelines where it states:

"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. In the absence of such a notation, at least ten systems must be individually documented."

Sorry to say that some Medicare carriers (like TrailBlazer) have said that they do NOT recognize this shortcut and will only give credit for each system listed. Check with your Medicare carrier before using this documentation shortcut


http://emuniversity.com/FAQ/EMFAQ9.html
 

January

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Family History

If the physician documents family history with a 0 and / through it, is that considered acceptable?:confused:
 

RebeccaWoodward*

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I believe this will depend on your carrier...

When documenting the patient's past, family, and/or social history, simply using the notation "Non-Contributory" or "negative" is not considered adequate documentation. Documentation must include social and/or family history information (such as alcohol consumption, smoking history, occupation, or familial hereditary conditions).

http://www.wpsic.com/medicare/part_b/publications/home_visit_doc.shtml

My carrier prefers... “reviewed and non-contributory/negative to patient’s illness” if there is absolutely no hereditary issues
 
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Family history negative

kte01A asks: So are we saying "family history negative" is acceptable or unaccepable?

Negative for what?

It only takes a half a second to say what the history is negative for ...
"Family history negative for problems with anesthesia or bleeding disorders" is the most frequent one I see our surgeons use on their H&Ps.

No one wants to pay for services that were not provided - Medicare, Medicaid, commercial insurances. I've shadowed my docs in clinic and I KNOW they are asking these questions, but they don't always document it! As I tell my docs, the only proof I have that you did something is if you have written it down, signed and dated it. And that's the only proof I can submit to the carrier who questions the level of service.

If you provided the service and want to code the correct level, then document to that level.

Okay ... off my soap box now ... I would probably count the statement "Family history is negative" ... but I'd try to educate the doctor to be more specific with some gentle nagging (and nagging, and nagging).

I hope that helps,

F Tessa Bartels, CPC, CEMC
 
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