Family History

Ethanzoe

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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. I am getting conflicting info from the auditor. Any input is greatly appreciated!

Thank you for your time,
:confused:
 
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jdibble

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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. I am getting conflicting info from the auditor. Any input is greatly appreciated!

Thank you for your time,
:confused:

For family history - some insurances may accept Non-contributory and some may not. We encourage our providers to state a negative to what they had asked - "no family history of lung cancer" instead. The use of unknown is however not acceptable as this implies that the question was never asked and therefore it is not known.

For a new patient - inpatient or outpatient - all 3 PFSH must be documented in order to bill a higher level E/M. If only 2 of the 3 are documented, then yes, the highest inpatient admit level would be 99221 - no matter how extensive the rest of the note!

For a ROS - Respiratory: no cough (or simply negative) would be acceptable. The ROS is a listing of both negative and positive responses about 14 organ systems. However, it would not be appropriate to say Respiratory: positive without further stating what was the positive finding.

Hope this helps!
 
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Unknown for family history can also apply if the patient does not know the information. For example, if the patient is adopted or if one parent has been absent from the patient's life.
 
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