tci ED Coding & Reimbursement Alert - 2012 Issue 1

Audit Proof Your History Component Coding Selections: Here's How

See this advice on using "Non-contributory" to document a ROS of past, family, social history.ED coders frequently wrestle with whether the documented phrase "non-contributory" for a history element satisfies the documentation requirements. The good news is help is here; read on for advice on solving this conundrum:The challenge: Does "non-contributory" indicate that the physician inquired about those elements and there was nothing about the response that contributed to the current presentation, or does it mean instead that inquiring about those systems would not be contributory to this presentation? The first might be ok to count towards the E/M...

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