Wiki family history

Create Wiki
K

krssy70

Guru
Messages
236
Location
East Providence, RI
Best answers
0
We are an Onoclogy speciality office - Our physician documented in the initial consult note what the family history is, and doesn't document family history in the current note, can we code the family history dx codes on the current claim. I am under the impression that because the family history doesn't change, and the physician documented in the initial consult note, but just didn't document in the current encounter, (follow up visit) that we can use the family history diagnosis code. Because we are an Oncology speciality, the family history dx codes are very important.

any help with this is greatly appreciated.

thank you
Kristen
 
I would not use the family history codes unless the provider documents them 'somewhere' in the current note. Somewhere meaning anywhere in the current note. Each document stands alone, UNLESS the provider wants to refer to his initial note with the date and where it can be located, then you could use them if he noted this. Very unlikely that this would happen. Best bet is to educate the provider that these type of diagnosis can not be inferred they must be documented each time the patient is seen in order to use them as a diagnosis.

Kelsey, CPC, CEMC
 
Thank you very much for your response. What if the physician states that the family and medical history has no changes but doesn't put the date the initial info is from?? can you still use that as documentation of the family and medical history and then code what the family history is?? I highly doubt it, but just seeing what others think as well..

thank you
Kristen
 
Need the date

With just "no changes" noted, no changes from what? The last visit? 5 years ago? No, I would need more information to give any PFSH credit.
 
I meant can i code the DX V16.3 family history of breast cancer.. if the note just states family history is unchanged. This is a dx question. sorry about that.
 
No you cannot code from that vague of a note , The guidelines are specific on this, the only information that can be extracted from a previous note referenced by date and location (per my office note of 1/3/13) is the ROS. Family history must be restated on each encounter. And family history can change, the patient could remeber more, or other family members could be currently ill.
 
Exactly, it isn't asking too much for your provider to just add the date that it was last documented, and state that it is unchanged since then. Something like "Past Medical and Family history is unchanged from his last visit on 7/15"

The only thing to be aware of is that I (as an auditor) should be able to access that 7/15 note and see the documentation. If the 7/15 note says "Unchanged from visit on 2/5" then we have a problem.
 
You must log in or register to reply here.
Top