Outpatient Facility Coding Alert - 2011 Issue 29
E/M Documentation: Documenting 'All Others Negative' Could Cost Your Physician $87 Per Visit
Subscribe or sign in to view the full article.
Article Overview
This article explains a documentation issue in evaluation and management (E/M) charting related to review of systems (ROS) entries commonly summarized as a broad negative statement. It focuses on how Medicare contractors and other payers may interpret that documentation, why practices should verify local requirements, and how auditing concerns can affect outpatient visit leveling. The piece is intended for physicians, coders, auditors, and billing staff who want to align documentation habits with payer expectations.
Why This Topic Matters
Variation in payer interpretation of ROS documentation can lead to claim downcoding, audit risk, and avoidable reimbursement loss if charts do not meet local requirements.
Article Sections
-
Require the Basics
Explains the general documentation framework for review of systems in E/M services and describes how payer expectations may differ from older assumptions.
-
Background
Summarizes the broader E/M guidance discussed in the article and the context for why the documentation shortcut became common.
-
The problem
Describes how carrier-specific review practices can affect whether documentation is considered sufficient for coding purposes.
-
What this means
Discusses the potential impact of documentation interpretation on visit level review and claim payment, including audit implications.
-
Hidden trap
Addresses the risk of relying on a routine documentation pattern without substantive review findings and the resulting audit concerns.
-
Stem Overuse With Common Sense
Reviews the need to match the extent of documentation to the clinical presentation and to avoid patterns that may appear unsupported.
What You Will Learn
- How review-of-systems documentation is discussed in the context of E/M charting
- Why payer-specific policies can matter for documentation review
- What kinds of audit concerns may arise from repetitive documentation patterns
- Why practices should confirm local contractor expectations before relying on common charting shortcuts
Who Should Read This
- Physicians
- Medical coders
- Auditors
- Billing staff
- Practice managers
Codes Discussed
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com