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krssy70

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If a physician documents that the Fam Hx and Soc Hx is Unchanged, but does not document what note he obtained the Hx from, Can I give him credit????? Also, is there a time frame of how far they can go back to obtain a HX????
 
He should definitely document what note or visit the Fam and Soc Hx came from originally. It is a good rule of thumb to make sure they are not referring to anything older than a year old.
 
So what you are saying is that if the physician does not document what note he was referring to for the Hx, he does not get any credit for documenting that the Hx is unchanged???

Also, Do you have any documentation that supports that he can go back one year to obtain a Hx from a previous visit? I need something I can show to the physicians if possible...Thank you for your response.
 
krssy70 said:
If a physician documents that the Fam Hx and Soc Hx is Unchanged, but does not document what note he obtained the Hx from, Can I give him credit????? Also, is there a time frame of how far they can go back to obtain a HX????
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A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

• describing any new ROS and/or PFSH information or noting there has been no change in the information; and
• noting the date and location of the earlier ROS and/or PFSH.

The provider does need to indicate the location and date of this previous information and make note of any changes. As for the time frame...the documentation guidelines don't provide a "time frame" ,per se,. I would not want to exceed a years time frame. I prefer not to exceed 6 months but have credited information that was older when documented appropriately.

http://www.cms.hhs.gov/MLNEdwebGuide/25_EMDOC.asp

Page 8 of the 97 DG~
 
Mine was the same for about 20 years

I agree with Rebecca's statements, and the guidelines are the official ones.

But just to add a little wrinkle ...

My own family and social history was unchanged for about 20 years.
I was living alone, never smoked, had a few drinks per week; my grandparents were deceased at my first visit, my parents and siblings, aunts, uncles and cousins were alive and without any health problems through that entire time period.

My doctor would ask me every year if anything had changed ... nothing had. Now, I don't know what he wrote down, but I can tell you from my own personal experience that it is certainly possible for this part of the patient history to be unchanged for a very long time.

F Tessa Bartels, CPC, CEMC
 
F Tessa,

I understand that a patients Fam Hx may not change for years, but from what I understand from the other posts is that, a physician can only go back 6-12 months, and must document where he pulled the Hx from. Hopefully your physician documented the Hx every year when you followed up with him/her. If I was coding that chart, I would not have accepted a unchanged history and would of addressed to him/her this info. Thank you very much for your response. :)
 
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