Documenting Negative or Normal for an Entire Area or System

 

 

Both the ’95 and ’97 Guidelines say: “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).” This article fully explains the rules regarding 1) when you can just document “negative” or “normal” for an entire area or system, and 2) how this documentation, when acceptable, should be credited when using each set of the E/M Guidelines.

 

Let’s first examine the part of the above provision that applies no matter which version of the Guidelines are being used: findings documented with a simple “negative” or “normal” notation are only valid for scoring purposes when they pertain to 1) an unaffected (body) area or 2) an asymptomatic organ system. So if a patient presents with complaints of lower back pain, then the affected area (the area that most directly pertains to the chief complaint) is the back, and affected system is the musculoskeletal system. Even if the doctor finds nothing wrong with the patient’s back or musculoskeletal system during the physical exam, he is simply not allowed to document these normal/negative findings by just saying that the back area or musculoskeletal system is “normal” or “negative”—at least, not if he wants credit for this documentation. Specific documentation, like “back negative for pain to palpation or when bending,” is needed.

 

You have a similar situation when the area or system being examined is symptomatic (though not the affected area/system tied to the chief complaint). For example, say the patient presenting with back pain is also experiencing constipation. This means that the findings associated with the abdomen body area and/or gastrointestinal system can’t be documented with a simple “negative” or “normal” even if they are found to be such during the exam. Specific negatives like “no guarding, tenderness, or masses present” is needed.

 

So to summarize this initial point, you first have to establish that the area/system the doctor is commenting on is NOT either the affected system or a system that is documented as being symptomatic. Only then do you move to the next step of considering how to credit findings documented as “negative” or “normal.”

 

When a provider uses the allowance of just writing “negative” or “normal” to indicate normal findings related to unaffected areas/systems, it gets counted differently depending on whether you are auditing based on the 1995 Guidelines vs. the 1997 Guidelines.

 

The ’95 Guidelines require a coder/auditor to label the study of a certain area/system as:

 

·         a “limited” exam of the area/system (mentioned in the definition of “Problem-focused” and “Expanded Problem-Focused” exams)

·         an “extended” exam of the area/system (mentioned in the definition of a “Detailed” exam)

·         a “complete” exam of a system (mentioned in the definition of a “Comprehensive” exam)

 

When “negative” or “normal” is documented as the summary status of an entire area or system in lieu of specific individual findings, you have to decide how much of an exam (limited vs. extended vs. complete) the provider should be credited with. Since this documentation allowance only pertains to the exam of unaffected and asymptomatic areas/systems, and it is reasonable to conclude that only a limited amount of time would be spent examining these unaffected/asymptomatic systems, most decide that it is best to credit this documentation as being a “limited” exam of a certain area or system.

 

The ’97 Guidelines, on the other hand, use bullet points to quantify the exam component, and though they contain the same allowance that “negative” or “normal” can be used to summarize findings for an entire system, no indication is given in these Guidelines as to how many bullet points this type of summary documentation would be worth. It is my policy and that of several others I’ve been in contact with to credit 1 bullet for the associated system for this summary documentation when using the ’97 Guidelines.

 

Seth Canterbury, CPC, ACS-EM

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