Wiki family history - their documentation

[Cynthia A]

Does a physician have to state why they are unable to obtain a family history even if this is documented throughout their documentation?

 

[LLovett]

How is it documented thru out the note?

There has to be some indication of why they can't get family history in order for them to get credit, ie patient is adopted no family history is known. Does it have to be under a header of family history, no it could be anywhere in the note.

Laura, CPC, CEMC

 

[cleanclaims]

I wouldn't want to assume that an auditor could find the documentation through out the rest of the report as you state. Please see this link:

http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf
page 8

"If the physician is unable to obtain a history from the patient or other
source, the record should describe the patient's condition or other
circumstance which precludes obtaining a history."

 

[LLovett]

Wow, I think you might be stricter than me! lol, its not often that I am the less conservative view.

Unfortunately there is nothing out there that requires notes to be structure in a particular order. PFSH are what they are, they can't be discovered on exam or diagnosed, so where ever that info is in the note, how could you not give them credit for it?

If an auditor dropped my level because they said PFSH was missing and I found it in the note, I would challenge them.

Obviously in a perfect world everything would be in its place, until that happens though we just have to deal with what we have. I am an auditor, I work with a lot of other auditors (mostly external to my organization) we may disagree on HPI and ROS but PFSH has never been an issue, now that I say that it will probably come up.

Laura, CPC, CEMC

 

[Cynthia A]

Thank you all for your responses.

If the physician is unable to obtain a history from the patient or other
source, the record should describe the patient's condition or other
circumstance which precludes obtaining a history."

with tht exact word being stated i take it to mean as long as it is stated somewhere in the record. I was challenged on this same issue as the Dr stated in the notes but when she documented the Family history she put down unobatainable so i down coded her visit

So, i am from now on going to give them credit for family history: unobtainable if somewhere in the RECORD it is listed as to why the patient cannot give information.

Blondemoment the link you sent was for 1997 guidelines. I use 1995 guidelines

Thanks again for all your help.