Wiki Recent Audit-entire ROS and exam unremarkable


Bolingbrook, IL
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Ive been asked to review documentation which was recently audited by a commercial payer. A couple of the notes have an ROS which every system is listed as 'unremarkable'. Also, in the exam section, all systems are listed as 'unremarkable' except one system. The auditor counted all these 'unremarkables' and came up with comprehensive ROS's and exams. I've always been taught not to accept 'unremarkable'. What would you do?


p.s. education is in progress with these docs ;)
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We give them credit for "unremarkable" but educate them and tell them in the future they have to say "negative" to get credit.
I don't give credit for unremarkable. I was mentored by auditors that have worked and continue to work for the OIG so I tend to be more conservative. The other one I see a lot and don't give credit for is "non-contributory", that is not even a medical term, it is a financial term. Just my take on it but again I'm conservative.

Laura, CPC
In my opinion, auditing is often a matter of interpretation. Many times, what works for one auditor doesn't work for another. What I do see to be a common ground is that most coders can argue their opinion and validate their view. I tend to agree with the last two post's.

"We give them credit for "unremarkable" but educate them and tell them in the future they have to say "negative" to get credit." ** I think this is a reasonable approach but then really depends on your Medicare carrier.**

"The other one I see a lot and don't give credit for is "non-contributory" **I couldn't agree more...I don't like this statement, nor do I allow it.**

The bottom line...I think "unremarkable", like anything else, should be used when applicable. I wouldn't use it as the norm...maybe the exception. This way, it wards off any scrutiny from Medicare or other carriers. The 95 and 97guidelines do acknowledge when this phrase can be appropriate.

!DG: The review of lab, radiology and/or other diagnostic tests should be
documented. A simple notation such as "WBC elevated" or "chest x-ray
unremarkable" is acceptable. Alternatively, the review may be
documented by initialing and dating the report containing the test results.

As coders, we can and do utilize sound judgement.
Try to teach to 97 guidelines

First as to the exam: I try to educate my physicians to the 97 guidelines (even though I might use the 95 guidelines when actually auditing). Why? Because the 97 guidelines are very specific about what constitutes a bullet point. "Unremarkable" wouldn't get you any bullet points with the 97 guidelines.

That being said, using the 95 guidelines, there could be a presumption on the part of the person auditing that the physician actually examined that system, but found nothing pertinent to report. So an auditor might give credit for "unremarkable" if s/he is following that thinking.

Again, I educate my docs to "document what you do, and I'll code what you document."

Now as to ROS: I educate my physicians that "unremarkable" or "non-contributory" lead me, as an auditor, to believe that the physician did not even review that system. So I give no credit for that phrasing. I WILL give credit if they list the pertinent positives and then indicate "all other systems reviewed and are negative." (Of course, they have to have actually reviewed them! ... This is where our patient questionaire comes in handy, with the doctor's signature & date of reivew on it.)

F Tessa Bartels, CPC, CPC-E/M
Follow-up question

Thanks everyone for your thoughts, now I have a follow-up question

so with some of these notes---


The auditor came out with 99214. I dont really understand this...

2/3 are needed for est visit and I understand how they're probably going off of the MDM, but according to the guidelines only 2 are needed and if they're using the Low MDM shouldnt it be 99213?

shouldnt it either be 99213 or 99215?
It is 2 out of 3 but there has to be medical necessity as well. Why would they do a comprehensive hx and exam for low complexity mdm? I agree that it would be a 99215 IF it is medically necessary, otherwise I would go with the 99213. I'm not sure how you could use 99214, that would be like averaging them out and as far as I know you can't do that.

Just my thoughts,

Laura, CPC
Here is my thoughts for what it worth... I think of ROS as from the patient's perpespective... afterall it is under history and this is history that is allowed to be obtained by ancillary personnel or the patient's fillinf out a questionair.. in the guidelines it states that this does not have to be redone each visit as it is history but the physician can refer back with a statement see ROS from visit of xxxx reviewed with patient and nothing changed. Now the examination is the physician's view of what is going on with the patient so if he states negative or noncontributory on the exam then it does not count, if you are using 95 or 97, the bullets on 97 are way too specifiec and the 95 sates that to be comprehenive it must be a complete exam which is defined as relevant findings of 8 out of 12 organ systems or a complete exam of a single organ system and noncontributory just does not get that. Anyway that is how I audit and I am not very lenient with the ones I do. Hope this is of some help.
Debra Mitchell, MSPH, CPC-H
My approach is to not give credit for unremarkable or non-contributory in the ROS. This is supported by trainings I went to through our local carrier. One peculiar thing I learned though was that these words are ligit in the PFSH section.
As for how they figured it to be a 99214 - I can't tell. This should either be 99215 based on Hx and Exam, or with MDM as the driving factor down to 99213. If these reviewers counted either hx or exam (or both) down to detailed for medical necessity, it should say so on their report.