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Thread Topic: the term non-contributory
Topic Originator: garsh50
Post Date April 10, 2008 @ 12:08 PM
the term non-contributory


garsh50
April 10, 2008 @ 12:08 PM Reply  |  Email Friend   |  |Print  |  Top

I thought we had trained our physicians not to use the term non-contributory when documenting the ROS or PSFH but now a couple of them are beginning to do so. Is it in writing anywhere that this is not acceptable because one cannot tell the intent of that term? Thanks.

sTEVE VERNO
April 10, 2008 @ 7:30 PM Reply  |  Email Friend   |  |Print  |  Top

all I can add is the following from the E.M documentation guidelines:

REVIEW OF SYSTEMS (ROS)
A ROS is an inventory of body systems obtained through a series of questions
seeking to identify signs and/or symptoms which the patient may be experiencing or
has experienced.
For purposes of ROS, the following systems are recognized:
" Constitutional symptoms (e.g., fever, weight loss)
" Eyes
" Ears, Nose, Mouth, Throat
" Cardiovascular
" Respiratory
" Gastrointestinal
" Genitourinary
" Musculoskeletal
" Integumentary (skin and/or breast)
" Neurological
" Psychiatric
" Endocrine
" Hematologic/Lymphatic
" Allergic/Immunologic
A problem pertinent ROS inquires about the system directly related to the
problem(s) identified in the HPI.
!DG: The patient's positive responses and pertinent negatives for the system
related to the problem should be documented.
An extended ROS inquires about the system directly related to the problem(s)
identified in the HPI and a limited number of additional systems.
!DG: The patient's positive responses and pertinent negatives for two to nine
systems should be documented.
A complete ROS inquires about the system(s) directly related to the problem(s)
identified in the HPI plus all additional body systems.
!DG: At least ten organ systems must be reviewed. Those systems with
positive or pertinent negative responses must be individually
documented. For the remaining systems, a notation indicating all other
systems are negative is permissible. In the absence of such a notation,
at least ten systems must be individually documented.

The PFSH consists of a review of three areas:
" past history (the patient's past experiences with illnesses, operations, injuries
and treatments);
" family history (a review of medical events in the patient's family, including
diseases which may be hereditary or place the patient at risk); and
" social history (an age appropriate review of past and current activities).
For certain categories of E/M services that include only an interval history, it is not
necessary to record information about the PFSH. Those categories are subsequent
hospital care, follow-up inpatient consultations and subsequent nursing facility care.
A pertinent PFSH is a review of the history area(s) directly related to the
problem(s) identified in the HPI.
!DG: At least one specific item from any of the three history areas must be
documented for a pertinent PFSH .
A complete PFSH is of a review of two or all three of the PFSH history areas,
depending on the category of the E/M service. A review of all three history areas is
required for services that by their nature include a comprehensive assessment or
reassessment of the patient. A review of two of the three history areas is sufficient
for other services.
!DG: At least one specific item from two of the three history areas must be
documented for a complete PFSH for the following categories of E/M
services: office or other outpatient services, established patient;
emergency department; domiciliary care, established patient; and home
care, established patient.
!DG: At least one specific item from each of the three history areas must be
documented for a complete PFSH for the following categories of E/M
services: office or other outpatient services, new patient; hospital
observation services; hospital inpatient services, initial care;
consultations; comprehensive nursing facility assessments; domiciliary
care, new patient; and home care, new patient.



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