“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/