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LewinFamily

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This is what my doctors are putting for ROS. I believe that this is unacceptbale since they are not stating negative or positive nor stating that they reviewed the ROS from a prior note or anything and uncontributory means nothing without additional info provided. What are your thoughts?

All other systems were reviewed and found to be as above in History of Present
Illness, Past Medical History, Past Surgical History. Otherwise found to be
noncontributory or unremarkable.
 
As long as there are positives and pertinent negatives found in the HPI, I would count this statement as a complete ROS per Medicare Documentation Guidelines.
 
There aren't positive or negatives aside from the main system (GU) and allergy (NKA).. So I was putting this as an extended ROS since they are only mentioning 2 systems in their HPI, PFSH. But they are feeling that this would be a complete ROS since they have this statement.
 
It is probably better practice to state all other systems reviewed negative (instead of uncontributory). However, if the positives and pertinent negatives are mentioned in the HPI, there is no need to restate them. It is perfectly fine for provider to state ROS per HPI, all other systems reviewed and are negative or non-contributory.
 
ok. I was under the impression from my research that by statingnon contributory only is UNACCEPTBALE... That they would have to list all other systems individually and state negative or positive OR that they would have to state all other systems are negative. In this statement, they are not stating that all othEr systems are negative.. they are only stating non contributory or unremarkable (which is also not acceptable). Am I understanding this right?

Here is some other thoughts from other forums too:

We are transitioning into an EMR and I was very vocal about the "non contributory" statement. This statement is no longer an option.
__________________
Rebecca CPC, CPMA, CEMC

I agree with Rebecca (and many others) ... the rules are that "non contributory" does not count.

But I understand the ER doctor's point ... how can a family history (diabetes, stroke, HTN, cancer) be relevant to a trauma? I've trained my trauma surgeons to always ask about family history of bleeding disorders or reaction to anesthesia. Those kinds of family issues WOULD be relevant to treating a trauma case.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
If I'm reading it correctly

If I'm reading the statement your doctors are using correctly (punctuation is SO important) ... then they are saying they have reviewed all systems and except those specifically listed in HPI, Past Medical and Past Surgical History, the others are noncontributory or unremarkable.

Two little things would help immensely here. 1) DROP the word "other" at the beginning of the statement - just start with "All Systems Reviewed.." 2) See if you can train them to substitute the word "negative" (DROP "noncontributory and unremarkable"). That would cover them.

IMPORTANT NOTE: Some carriers require that each system be individually noted, and will not accept any of the variations of "all others negative." If your carrier is one of them, then you can only count those systems that are specifically listed.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
As F. Tessa says above, some Medicare contractors will not accept "noncontributory," and Palmetto GBA has published guidance stating it is unacceptable to use the verbiage when documenting past, family or social history.
 
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