decisionhealth Newsletters, Part B News - 2004 Issue 4 (April)
Getting Credit for 'Noncontributory' Systems
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Article Overview
This article discusses documentation practices for evaluation and management (E/M) services, focusing on how CMS has addressed the use of the term noncontributory in review-of-systems and past/family/social history documentation. It is relevant to physicians, coders, auditors, and compliance staff who review E/M records for support of history elements and documentation completeness.
Why This Topic Matters
Understanding the documentation language discussed here can help readers assess whether an E/M record supports billed history components under CMS guidance and how auditors may interpret common shorthand in the medical record.
What You Will Learn
- How CMS has addressed the use of noncontributory language in E/M documentation
- How review-of-systems documentation is discussed in relation to completeness
- How past/family/social history documentation is treated in the context of E/M history taking
- Why some coders recommend more explicit wording in documentation
Who Should Read This
- Physicians
- Medical coders
- Auditors
- Compliance staff
- Billing staff
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