Wiki PFSH - "Non-contributory"

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SHIBA425

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Does anyone have any thoughts or guidelines on the following situation:

A Provider will list a Past History in detail, a Social History in detail, but will state Family History is "non-contributory".

My practice has always been "non-contributory" is a vague statement, and the Auditor has no way of knowing if a question was asked, was asked and was not pertinent or was asked and was pertinent to the current illness/injury. An Auditor should not give credit for a statement of just "non-contributory" without elaboration. I would also recommend to the Provider to either document the Family History or make a statement of "the patient's family history was reviewed and does not contribute to this illness/injury. The Provider should be clear that the Famliy History was reviewed.

Is this acceptable or is there something I am missing? I look forward to all responses.

Thanks
Jean
 
I completely agree, as I have stated before, non-contributory is not even a medical term.

You only have to have 1 element to qualify, they could say just about anything to get credit.

Laura, CPC, CEMC
 
"Non-Contributory" = No credit

I do not give credit for simply stating "non-contributory." As Laura mentioned they only have to say one or two words. Family history may be "unavailable due to adoption" but it is rarely non-contributory. Even a patient presenting with an acute injury may have a family history of bleeding disorders, or difficulty with anesthesia that should be investigated and documented.

F Tessa Bartels, CPC, CEMC
 
no credit

No credit for "non contributory" given here either. It could mean that the provider DID ask about family history and it was not pertinent, or that they didn't ask at all becuase they really didn't want to know.
I advise providers when I meet with them to write "Reviewed - non contributory" or something to that effect to indicate that the work was indeed performed.
 
Non-contributory

http://www.wpsic.com/medicare/part_b/publications/em_history.shtml
When the terms "non-contributory" or "negative" are used in PFSH documentation, the documentation might indicate "Past medical history is non-contributory" or "Social history is non-contributory." Such documentation would not indicate the provider had actually addressed the issues. It must be clear that the PFSH was discussed with the patient. To use the term "non-contributory" alone does not clearly indicate PFSH was addressed.
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Pfsh

Thank you to everyone who responded. I am glad to hear that I am not alone. I apperciate the thoughts and links that were given.

Have a great weekend.

Jeanne
 
Non contributory or Negative for ROS

I was at a meeting last week where the speaker said the use of "non-contributory" or "negative" was not acceptable in documenting the ROS. For example, a physician asked if he could document Tympanic membranes (TMs) - negative and he was told that would not be acceptable to an auditor. Just wanted to get feedback from others.
 
dtisonyai said:
I was at a meeting last week where the speaker said the use of "non-contributory" or "negative" was not acceptable in documenting the ROS. For example, a physician asked if he could document Tympanic membranes (TMs) - negative and he was told that would not be acceptable to an auditor. Just wanted to get feedback from others.
Click to expand...

The 1997 E&M guidelines specifically states that if you document the positive responses in the ROS and document "all other systems negative", that this does meet documentation guidelines. Download the 1997 E7M Documentation from the CMS website and read page 8, which concerns ROS. The statement I am referring to is near the bottom.
 
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