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How specific does your documentation need to be?

Don't shortchange yourself with sparse documentation

Keywords: Specifics to help physicians improve billing documentation

by Kristy Welker, CPC

Published in the July 2013 issue of Today's Hospitalist

ARE YOUR BILLS BEING DOWNCODED by auditors or others reviewing them? Chances are the culprit is too scanty documentation for the history and exam elements.

What's new in coding ? Keep up with the latest: ICD-10 Coding Surprises Coming in 2016

Getting these elements right is a must to make sure that documentation supports the level of service that you bill. Here are a few questions from readers on guidelines for documenting history and exam, and some answers.

ROS and exam specifics
We use a template for our preoperative
Statements such as "ROS negative" or "negative other than in the HPI" don't support performing a complete ROS.

consults that covers the 12 systems for our review of systems (ROS) and all body systems for our physical exam. In terms of what we document, how much do we need to include as specifics for each of these?

I've heard that we can just document the main complaints and abnormalities, then note that the others in the 12-point ROS were negative. But I've also heard that we should have at least three negative findings documented in each system. And I have the same question for the physical exam: How many "normal" items do we need to document per organ system to consider billing a comprehensive physical?
The "Evaluation and Services Management" guide put out by the Centers for Medicare and Medicaid Services (CMS) does not give a required number of negatives per system that you need to document. Instead, the guidelines direct you to document all positive and pertinent negative responses for the review of systems.

It is still acceptable to use the statement, "All other systems were reviewed and are negative." But a word of caution: When using the "all other systems reviewed and negative" statement, make sure you're performing a 10-plus system review. The statement is a documentation shortcut, not a performance one, and physicians still need to review at least 10 systems.

Also, your documentation should clearly communicate performing a "complete" review of systems. You can do so with the "all other systems were reviewed and are negative" example or, as you stated in your question, "others in the 12-point ROS were negative."

But statements such as "ROS negative" or "negative other than in the HPI" don't support performing a complete ROS. If you don't use the "all other systems" statement, you must individually document findings for at least 10 systems.

As for the exam, the "Evaluation and Services Management" guide likewise does not spell out a required number of normal or negative findings. The 1995 guidelines define comprehensive multisystem exam as the exam of eight or more organ systems.

Here are a few quotes from the "Evaluation and Services Management" guide on exam points:

  • "[S]pecific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of 'abnormal' without elaboration is not sufficient."

  • "Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described."

  • "A brief statement or notation indicating 'negative' or 'normal' is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s)."

Another tip to keep in mind to help clarify that last point: Don't use a simple "negative" or "normal" statement as your only documentation of the exam for the system(s) related to the presenting problem. For instance, when examining a patient who presents with chest pain, don't document "Cardiovascular: negative." Instead, document specifics of that cardiovascular exam, even if all your findings are negative.

Previously documented history
I work with a large hospitalist group and have used your column, "Seven mistakes to avoid when billing subsequent visits" (September 2006). In that column, you state that providers can refer to previously documented history as long as they include the date the previous history was taken and give an update.

Did you mean to include the history of the present illness (HPI) in that statement? This is the first time I've heard that doctors can update a previous HPI.

I should have been more specific. Clinicians can update only previously documented review of systems and past, family and social history. Doctors should specifically reference the date and location of the review of systems and past, family and social history being updated. They should then document any new problems or changes to that information or state that there are no changes.

Unresponsive patients
Say a patient is unresponsive or otherwise unable to provide the review of systems for the initial admission history and physical. How should we document that so we can bill a higher level than a level one initial hospital visit (99221-99223)? Do we have to document time spent? Or can we bill critical care time if the patient's condition warrants it and the physician meets documentation guidelines of spending at least 30 minutes providing critical care services? And what if the patient is demented and gives an inaccurate review of systems?
If you aren't able to obtain a history from a patient or other source due to the patient's clinical conditionóbeing intubated, comatose or mentally impaired, for instanceódocument the specific reason why you could not take a history. You should be able to receive credit for a comprehensive history in such situations, but you may want to confirm that with your carrier.

Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at We'll try to answer your questions in a future issue of Today's Hospitalist.

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