How much documentation of negatives does HCFA require?
All positive findings must be described. Negative findings do not need to be
individually documented except as appropriate for patient care. A notation
indicating a system was negative is sufficient. The name of each system
reviewed must be documented.
"Pulmonary: cough x 4 weeks, otherwise negative"
"ROS: Cardiac, pulmonary, GI, GU, endocrine all negative"
"All systems negative"
This tip is excerpted from a recent issue of The Green Sheet, a newsletter on compensation and reimbursement for nurse practitioners, published monthly by the Law Office of Carolyn Buppert.
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