Wiki Family history - I was wondering if someone could point me

[audrabullard@ymail.com]

I was wondering if someone could point me in the right direction on the importance of family history for an E/M visit. I was told if family history is not documented for a new patient, automatically you are knocked down a level. I need some guidelines that I could print out for a Dr.
Thanks

 

[OCD_coder]

A family history needs to be querried and documented for a complete PFSH such as for New patient and Initial Inpatient CPT code sets. If the family history element is missing or cannot be given credit with insufficient information (eg. Noncontributory) then it may cause the reducing in E&M service reportable. This could mean the difference between a 99205 and 99203 or a 99223 or 99221.

Note: A comprehensive PFSH for Emergency Department only requires 2 of 3 Past, Family and/or Social History elements to meet the requirements.

This information is found in the CMS 1995 Documentation Guidelines, pages 8-9.