Terminology in Medical Records

Appropriate and Safe Use of “Normal” and “Noncontributory”

Consider the following medical record entries written by three different Clinicians documenting a cardiovascular examination of the same patient.

PMI at 4th-5th left intercostal space, small amplitude

No thrills, lifts, or palpable S3 or S4 No murmur, S3 or S4 to auscultation 

Rhythm regular

Carotid arteries with normal pulse amplitude, without bruits or delay

Abdominal aorta not enlarged, no bruits

Femoral arteries with normal pulse amplitude, no bruits

Pedal pulses palpable with normal amplitude

Extremities without edema, varicosities 

Entry 2

Entry 3

All three entries document a normal cardiovascular examination in varying degrees of detail. Here are the pros and cons of the three ways of making this entry. The documentation in entry 1 is time-consuming but tells the clinicians who follow, as well as auditors for payers, exactly what was examined and the specific findings. Entry 2 tells the clinicians who follow and payer auditors exactly what was examined. The presumption is that no other examination was performed, and a following clinician cannot tell whether an S3 or S4 was listened for. While entry 3 is efficient timewise, the clinicians who follow cannot tell whether the examination was extensive or superficial.

Considerations in Using the Term “Normal”

The considerations surrounding the use of the term “normal” are three-fold—clinical, related to malpractice, and financial.

Clinical Considerations

With entries 2 and 3, if the patient returned and the examining clinician noted an S3, he/she would not know whether the S3 is new or whether the clinician who wrote “normal” did not listen for an S3. With entry 1, the clinician knows that the previous clinician listened and that there was no S3 at that time, allowing him/her to assume that any S3 now being heard is new and to proceed accordingly.

Malpractice Considerations

If the patient in this scenario had a heart attack the day after the note was written and sued the clinician, practice, and/or hospital for malpractice for failing to diagnose a heart condition, entry 3 does little to bolster a defense that the patient was well on the day examined. The credibility of entry 1 is much greater, while the credibility of entry 2 is somewhere in between.

Financial Considerations

Medicare administrators who audit documentation for payment purposes generally consider use of the term “normal” to be sufficient documentation. The 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).” Abnormal findings should be noted and expanded upon. However, when recording family history, Medicare requires clinicians to document the history obtained even if it is “noncontributory.” Failure to document family history is one common reason claims are reduced a level; for example, the visit is billed as a 99214, but Medicare reduces payment to 99213.

Lessons from Medicare

Here is what a Medicare administrative contractor says about documenting findings as “normal,” “negative,” or “noncontributory.” 

Review of Systems (ROS): Record pertinent positives and negatives and state “All others negative,” if others were examined.

Past Family Social History (PFSH): There are specific requirements for a “complete” past, family, and/or social history that must be present to achieve a comprehensive history, which is called for when billing a level 4 or 5 new patient office visit, a level 5 established patient office visit, or a level 2 or 3 initial hospital visit. Record the family history obtained even if it is “noncontributory.”

The following FAQ and associated Medicare contractor’s response should help clarify Medicare’s position.¹

Q: “Under limited circumstances, could the term ‘noncontributory’ be used as appropriate documentation to support the review of systems (ROS) and family history sections of the history component of an evaluation and management service (E/M)?”

A: “It is understood that there are circumstances where the term ‘noncontributory’ may be appropriate documentation when referring to the ROS and/or family history sections of the history component of an E/M service. Under the E&M documentation guidelines, it is noted that ‘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 use of the term ‘noncontributory’ may be permissible documentation when referring to the remaining negative review of systems. The term ‘noncontributory’ may also be appropriate documentation when referring to a patient’s family history during an E/M visit, if the family history is not pertinent to the presenting problem.

“The use of the term ‘noncontributory’ to document the ROS and PFSH for E/M services would be expected to be the exception  and not the norm when referencing both in a patient’s medical record.”

A Coder Speaks…

Here is what one coder wrote on this same issue in Today’s Hospitalist.² A reader asked if it is okay for a provider to indicate that a family history is “noncontributory” and wanted to know if he/she could do the same thing when performing a review of systems. The coder gave the following response. “The term ‘non-contributory’ has always been considered controversial.

It raises the bigger question of whether a physician actually asked the patient about his or her family history and found nothing, or whether the physician didn’t think the question was relevant and decided against asking about family history altogether. As a result, most of my colleagues in medical coding recommend staying away from the statement. Many worry that if you use this term and undergo an audit, your documentation for that patient won’t hold up under scrutiny. One practice I recently talked to uses a slight twist on the phrase that might get around this problem. In this group’s documentation, coders note that a question about family history was ‘asked and is non-contributory.’ This tells anyone reviewing your records that the appropriate questions were indeed asked and that the findings were not relevant to care.”