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Adoption/Family History

  1. #1
    Default Adoption/Family History
    Medical Coding Books
    I am in the middle of an audit and not sure what to do. My physician documented "Pt was adopted and family hx is unknown." Should I credit the physican for attempting to get family history?
    I've learned that if a physican is unable to obtain pertinent history and states why, he/she can get credit and I'm wondering if the same concept would apply here.
    Any thoughts
    Thank you!
    Carrie, BS, CPC

  2. #2
    I would give credit for that. He tried to obtain and the patient provided all the information they had.

    Laura, CPC

  3. #3
    I would credit it as well. If they're adopted and don't know, well they just don't know...and as long as the documentation does say unable to obtain hx due to adoption or what have you...I would count it.

  4. #4
    Milwaukee WI
    Default Yes to family hx
    Actually, I see this a fair bit in pediatrics. Definitely give full credit for family history this kind of statement.

    F Tessa Bartels, CPC, CEMC

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