Don’t Sweat "No Fever" Medical Billing

When a patient presents for emergency management services with various symptoms pertaining to the flu and no fever is found, you may be questioning exactly what should be noted in the medical necessity and other medical documentation sections of your medical billing form.

You will not want to use this information under the history element. The 1997 “Documentation Guidelines for E/M Services” does not reference pertinent negatives in the context of the history of present illness (HPI). Instead, it references pertinent negatives in the context of the review of systems (ROS). Be certain not to check the associated signs and symptoms box of HPI. Instead, you should count the statement toward review of the relevant system (constitutional symptoms, e.g., fever in this example) under the ROS because this is a pertinent negative for ROS.

So, even though your patient has no fever, the reason for the visit to the emergency room can then be documented to show medical necessity and rule out other complaints such as fever and ascertain a solid diagnosis for the reason for the visit.

Remember, when you do your medical documentation, it is a good idea to include negatives to show the carrier that services were rendered and to build a whole picture of the reason for the patient presenting in the first place. This gives an entire picture of the health situation at the time and makes it easier for carriers to render payment for services provided.

View all Articles by: Melissa Clark, CCS-P