Medical Necessity-Family History


Heiskell, TN
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When dealing with trauma patients, our doctors typically do not document family history on the hospital admission, because it is truly non-contributory. The pt can sometimes be alert and still seriously injured, so to say family history is always unobtainable is not necessarily correct.

But because these are inpt admissions 99221-99223, according to Medicare Guidelines all 3areas of history are required.......but what are trauma doctors to do? "Excuse me, I know you are bleeding to death, but what's your family history?"

Our services are more comparable to ED services (where only 2 areas of PFSH) are required.....but we are fully admitting the patient so we have to report 99221-99223.

My question is can Medical Necessity play a part in us not asking the family history on 99221-99223? Would this fly with Medicare?

Pam Brooks

True Blue
Local Chapter Officer
NAB Member
South Berwick, ME
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Medical necessity is the overarching criteria for the level of E&M service. Coders and auditors disagree as to whether bullet-counting indicates "medical necessity" all the time, so you might see lively discussion here, but you're absolutely correct, in my opinion. Family history may not be relevant or medically necessary in a trauma case. We often see this same issue with our intensivists; how often would family history play a part with a 95 year old patient? Apparently, they have excellent family history....being alive still at 95!! If all other key components are met, particularly your MDM, I'd definitely bill out your higher level admission, as long as the note as a whole supports that the FH is irrelevant, but the comprehensive work was done. We shouldn't have to encourage our providers to fabricate documentation in order to support a certain level of services. E&M coding is not a one-size-fits-all endeavor. I'm sure many of my colleagues would agree.

However, it makes sense to indicate "Family history is non-contributory with regard to this case", or something like that, just to indicate that it was acknowledged as being a non-issue, but you have an excellent argument that I believe you can support.
Milwaukee WI
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Family history for trauma

Our trauma surgeons ALWAYS ask if there is any family history of bleeding disorders or difficulty with anesthesia. Both are medically relevant for any patient headed to the OR.

If the patient said he "passed out" and lost control of the car, you'd want to know the patient's own past history of seizure or DM or HTN or ?? But you'd also want to know if there is any family history of these conditions.

Hope that helps.

F Tessa Bartels, CPC, CEMC