Wiki Family History Documentation

[jsvinson]

Our auditors dropped a physician charge from a 99223 to a 99231 because under the Family History the physician documented "none". Is "none" not acceptable?

 

[Tonyj]

Our auditors dropped a physician charge from a 99223 to a 99231 because under the Family History the physician documented "none". Is "none" not acceptable?

There should have been more stated than just "none". Was it unobtainable and why? Was the patient a poor historian? "non-contributory" would be acceptable for some payors.

 

[jsvinson]

I spoke to the provider and he stated that he said "none" because there weren't any factors for family history. I didn't know if this would fly or not since it was the only reason it dropped the code down to a level1.

 

[wrightju1]

Take this as a "educate and move on" opportunity. I spend all day helping providers improve their documentation and nothing brings the lesson home like an auditor down-coding. Non-contributor is the way to go unless it is unavailable, and then the documentation should state why it is so.

 

[ckahlandt]

Our doctors say in the dictation that "Past medical, surgical, social and family histories were reviewed with the patient along with current meds and allergies" or usually something along those lines. Would this hold up in an audit?

 

[Thouvenel]

I am really curious as to why auditors are down coding these visits if there isn't anything in the family history. My physician is a GI doc, and he doesn't feel that family history is pertinent to why he is seeing the patient. Any guidelines or information I can pass on to him will be wonderful.

 

[FTessaBartels]

Family history MAY be relevant

I am really curious as to why auditors are down coding these visits if there isn't anything in the family history. My physician is a GI doc, and he doesn't feel that family history is pertinent to why he is seeing the patient. Any guidelines or information I can pass on to him will be wonderful.

I work for surgeons ... when they see an emergency room patient I've educated them to ask and document whether there is any family history of Bleeding disorders or adverse reaction to anesthesia.

These two questions ARE relevant to a potential emergency surgery.

For a GI doctor ... might there be family history of Crohn's disease, diverticulitis, colon cancer, GERD, food allergies, etc? I'm not a GI specialist but I thought those up right off the top of my head.

Hope that helps.

F Tessa Bartels, CPC, CEMC