Adequate Family History?

thelton

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I need opinions from auditors....would you give credit in the family hisotry for the following statement: No relevant family history. Patient is a 4 week old infant with fever and vomiting. Let me know what you think....I don't want to send my docs in the wrong direction! Thanks!!
 
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I'd rather see

I'd rather see something like: no family history of gastritis in recent weeks or "Family history: no sick contacts"

However, I would give him credit for this statement because he states there is no relevant history (which implies that he asked and nothing came up) and also states the acute nature of the problem for this infant.

ALSO ... if he's considering prescription treatment he might want to ask if there is any family history of drug allergies.

The key is that the history should be RELEVANT to the problem.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

MikeEnos

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I'd rather see something like: no family history of gastritis in recent weeks or "Family history: no sick contacts"
Interesting, I usually count "No sick contacts" as social history. I figure Medical history is illnesses, surgeries, medications etc that this patient has or has had in the past. Family history includes diseases or illnesses that could be hereditary that might contribute to the patient's problem(s.) Social history is anything that describes environmental factors that could contribute to the patient's problem(s) - living arrangements, occupation, drug use, sexual history, etc.

I usually see the phrase mentioned in the HPI - but I suppose if it was listed exactly as you showed it, "Family History: no sick contacts" it could be counted as family history, since the CMS E/M Services Guide only states that family history is: "A review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk" this seems to include illness that is not hereditary.

Thanks, Tessa!

Now to answer the question at hand. Obviously, the best practice is to specifically list positive/negative findings throughout the note whenever possible. Social history and medical history are virtually always present. Family history is one area that some providers sometimes describe is non-contributory. It isn't ideal, because it doesn't tell the auditor of whether it was checked, and was non-informative, or if rather it wasn't checked at all, because it wouldn't medically have made a difference (for example a 95 year old seen in the hospital by a cardiologist.)

I found that most MAC's do not accept the phrase 'non-contributory' when describing family history. In fact, the only one I found that does accept the phrase is NGS, who happens to be my MAC. I believe NHIC also accepted it, but they are no longer a MAC anyways. I usually give credit when I see it, but will advise the providers to consider documenting a pertinent negative finding instead to ensure credit is given.

NGS has a few sources where stating they do accept it. Here's one (emphasis mine):
Q5. Are the terms “unremarkable” or non-contributory” acceptable when documenting exam findings? Would the use of these terms denote a normal finding?
A: This would depend largely on the context of the note. The use of “unremarkable” to describe an individual normal finding may be acceptable if the actual body/system is specified. It would not be acceptable to say that the entire exam was unremarkable. To support the medical necessity of the visit there must be some findings in the exam related to patient’s complaint, symptoms, or problem that provider could elaborate on. The term “non-contributory” might be appropriately seen in the PFSH section, but not in the exam. The physician performing the exam should comment on his/her findings
 
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