Part B Insider (Multispecialty) Coding Alert

Reader Question:

'None' May Not Be Good Enough Answer When Recording Family History

Published on Fri Jan 13, 2012

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Question: Our physician often records the word "none" under the "family history" section of his E/M notes for a privately-insured patient. To me, that isn't comprehensive enough for me to count as being completed, but the physician disagrees. In my opinion, it would only count if the doctor recorded something more along the lines of "none that relate to the present illness/injury." Can you advise?

Delaware Subscriber

Answer: The answer comes down to the auditing rules that your payer maintains, but most consultants agree that they would only give credit for "none" toward family history if the condition was specified to indicate that "none" pertains to a specific history for which information had been provided.

For instance, if the patient was being seen for a fast heartbeat, the physician might record, "The patient reports no family history of cardiovascular disease." This demonstrates that a family history was performed, but the patient didn't report anything related to the visit. If the doctor simply records "none," it's unclear whether he actually performed the history.

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Reader Question:
'None' May Not Be Good Enough Answer When Recording Family History
Question: Our physician often records the word "none" under the "family history" section of his [...]

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