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Lynda Wetter

Lynda Wetter

True Blue
Local Chapter Officer
Messages
515
Location
Glen Allen, VA
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Family History "noncontributory"
Not sure how i feel about giving credit for this. especially for my upcoming exam.
Thoughts and facts are appreciated!!!

Lynda Wetter,CPC
 
I don't accept this term nor does my Medicare carrier...

Jurisdiction 11 Part B
Is it acceptable to use 'noncontributory, unremarkable or negative' when reporting past, family or social history?

Answer:

No, because the statement 'noncontributory, unremarkable or negative' does not indicate what was addressed. Did the nurse or physician ask specific conditions (i.e., any family history of coronary artery disease)? If for some reason you cannot obtain the family history, the documentation must support the reason why (e.g., the patient was adopted).

Resource(s):

E/M Documentation Guidelines



last updated on 10/02/2012


http://www.palmettogba.com/palmetto...Asked Questions~EM~8EEM6K6862?open&navmenu=||
 
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