PFSH statment?

[Lynda Wetter]

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

 

[RebeccaWoodward*]

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=||

 

[Lynda Wetter]

Thank you, Just wanted clarification before sitting for the CEMC!
Thanks!

 

[Lynda Wetter]

AND I'm in the same Jurisdiction!!!!

 

[RebeccaWoodward*]

AND I'm in the same Jurisdiction!!!!

You are welcome. I wish you the best on your test!