Internal Medicine Coding Alert

Published on Thu May 04, 2006 PDF

Question: If an internist marks a Medicare patient's history element as "noncontributory," should I count the notation toward FH?

Michigan Subscriber

Answer: No. Medicare auditors will not give credit for a history element that a physician documents as "noncontributory." The term implies that the physician felt it was not necessary to ask a patient about that item.
 
Better way: Encourage the internist to record something specific about the patient's family history (FH). Compare these two hospital admission notes for an 85- year-old patient who presented to the emergency department for chest pain:
 
Chart 1: "The patient is 85 years old, presented to the emergency department for chest pain. Family history is noncontributory."
 
Chart 2: "The patient has no family history of early coronary disease."
 
Although both notations indicate that a family history of heart disease has no role in the patient's condition, only the internist who wrote chart 2 should receive credit for the element under FH. Instead of offering information, chart 1 implies that the physician thought the patient's status was unimportant and therefore did not inquire about it.
 
Actually, the physician is saying, "It does not matter whether this patient's mother and father are still alive or not. This patient lived into his mid- or high 80s, and this is the first time he is coming in with a suggestion that he has some sort of coronary disease."
 
In contrast, chart 2 offers concrete information about the patient's history and therefore shows that the internist inquired about this area. Other acceptable notations include statements such as "Father died at 50 of a stroke" or "Mother is alive and well."
 
Do this: Follow the same rule for review of systems (ROS), social history (SH), and past history (PH) -- if the internist documents "noncontributory," do not give him credit for the statement.