The physicians I code for routinely use Noncontributory,Irrelevant due to age and unknown for the family history of the patient. These are not appropriate responses am I correct? Also for a new patient all 3 histories must be covered and if one is missed the code would go the whole way back to a 99221 for an IP H&P correct no matter how extensive the rest of the note is? Also would appropriate responses for the ROS be example: Respiratory: No cough.
One thing to remember is that sometimes the PFSH information isn't listed in just one place. It can be anywhere in the documentation for an encounter.
Another thing, CPT guidelines and guidelines provided elsewhere, such as those by CMS, don't always match. CPT guidelines just distinguish PFSH as pertinent (1/3) or complete (2/3 or 3/3). Other resources will say a new pt office visit requires 3/3.
My local MAC has this information, which may or may not help (keep in mind this is from a Medicare/CMS-standpoint):
Q. If Noridian audits by medical necessity, and all key components are not met, would it still be appropriate to bill a high level of service ( i.e. admit CPT code 99222 ) if past family and/or social history (PFSH) are not documented?
A. Noridian is still bound by CMS regulations to ensure all key elements are met however; CMS also states that medical necessity is the overarching criteria in determining payment. (I posted the explanation of this below)
Q. For an established patient visit, physician reads the patient's PFSH to refresh his memory without verifying the PFSH with the patient; He asks "Anything new?" to which the patient responds, "No." If the MD
references the prior note with PFSH, may we count PFSH for the review of systems (ROS)?
A. The PFSH may be counted if it is relevant to the reason for the visit and yes, reporting "unchanged" is appropriate, if medically necessary for the issue being treated/reason for visit. If notes are requested, send the records with the old PFSH.
Q. If family history is noncontributory to the
acute problem and is not asked by the physician, may we count "family hx = noncontributory" as family history towards ROS?
A. No, if not inquired about and if it has nothing to do with the chief complaint, family history would not be counted.
Q. If one of the established patient E/M components is missing, (history, exam or medical decision making (MDM), is the documentation still billable?
A. Yes, it is still billable but, if one of those components is missing the medical necessity of the service which is the overarching criterion may not be met.
"The following is an excerp from the CMS Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.1,
"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported."
Medical necessity cannot be quantified using a points system. Determining the medically necessary level of service (LOS) involves many factors and is not the same from patient to patient and day to day."
In your examples, "Noncontributory" would need to be "Reviewed; Noncontributory" or something similar to count. "Irrelevant due to age" clearly implies there was no review done, therefore not countable. "Unknown" would need to be accompanied by a reason, such as the patient doesn't know if there's a history of such and such in the family or that the patient is unconscious
