Wiki Can this be counted for PFSH

[perkins05]

Family History was reviewed and was noncontributory.

Thanks for any and all responses

 

[RebeccaWoodward*]

Family History was reviewed and was noncontributory.

Thanks for any and all responses

Typically, carriers do not accept this statement.

Is it acceptable to use 'noncontributory, unremarkable or negative' when reporting past, family or social history?

Answer:
No, because the statement 'noncontributory, unremarkable or negative' does not indicate what was addressed. Did the nurse or physician ask specific conditions (i.e., any family history of coronary artery disease)? If for some reason you cannot obtain the family history, the documentation must support the reason why (e.g., the patient was adopted).

Resource(s):

E/M Documentation Guidelines



last updated on 12/14/2011


http://www.palmettogba.com/palmetto...Asked Questions~EM~8EEM6K6862?open&navmenu=||

 

[perkins05]

Thanks

 

[FTessaBartels]

Family History was Reviewed

On the other hand ....

The provider does state that the family history was reviewed. So I would be tempted to count it, especially if I found any evidence of a questionaire completed by patient.

HOWEVER ... if the documentation read: Family History noncontributory ... I would NOT count it, because I'd have no way of knowing whether it was reviewed at all.

The BEST way to avoid this controversy is for the physician to get in the habit of being specific: Family history negative for any related diseases or syndromes.

Even with trauma I've trained my surgeons to ask and document family history of problems with anesthesia or bleeding issues. THAT is relevant to the proposed surgical intervention.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[Sueedwards]

I would count it as well because he did mention that he asked and it is non contributory.

thanks, Sue