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,
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!
