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“Reviewed” Not Sufficient Documentation

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  • September 15, 2015
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“Reviewed” Not Sufficient Documentation

by John Verhovshek, MA, CPC
Documentation stating “Family History Reviewed” is insufficient to satisfy evaluation and management (E/M) documentation requirements. Both the 1995 and 1997 documentation guidelines specify, “A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record.
Specifically, according to the documentation guidelines, the review and update may be documented by:

  • Describing any new ROS and/or PFSH information or noting there has been no change in the information
  • Noting the date and location of the earlier ROS and/or PFSH.

At minimum, the provider reviewing the record would want to document verbiage such as “Family History reviewed from [date of previous visit] is unchanged.”E/

Evaluation and Management – CEMC

John Verhovshek
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About Has 573 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

No Responses to ““Reviewed” Not Sufficient Documentation”

  1. Sabrina says:

    I’m very happy to see this as I’ve thought that “reviewed” was insufficient for sometime. However, with that said, I manage the audit and education department for a 400+ provider group who will challenge this without something to back it up from an entity that governs guidelines, such as CMS. Do you have anything additional that indicates that this additional documentation would be required in 2016?