Wiki Pfsh - When coding an inpatient

[skm510@live.com]

When coding an inpatient consult and the Dr. states "noncontributory" fot the family history. Would that statement be acceptable as one of the three components of the PFSH for a comprehensive consult? or would it drop it to a detailed?

 

[JDACPC]

The general consensus is this is not acceptable, but check your local MAC E/M guidelines. In their E/M FAQs, Novitas says this:

Under limited circumstances, could the term “noncontributory” be used as appropriate documentation to support the review of systems (ROS) and family history sections of the history component of an evaluation and management service (E/M)?

It is understood that there may be circumstances where the term "noncontributory" may be appropriate documentation when referring to the ROS and/or family history sections of the history component of an E/M service. Under the E&M documentation guidelines, it is noted that, "those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented." The use of the term "noncontributory" may be permissible documentation when referring to the remaining negative review of systems. The term "noncontributory" may also be appropriate documentation when referring to a patient's family history during an E/M visit, if the family history is not pertinent to the presenting problem.

Date Posted: 10/16/2009, Date Revised: 10/01/2012

 

[skm510@live.com]

Going to check with our local now... Thank you for the help!!