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Past,Social,Family history documentation

  1. Default Past,Social,Family history documentation
    Exam Training Packages
    hello everyone, i have a quick question. When a physician documents Past medical history: Denied. Is that acceptable documentation or not?

  2. #2
    I'm going with not on this one. They are not going to get credit for that statement.

    How can you deny having any past history? If the patient refused to answer that is different and should be stated as such then you would get credit.

    Laura, CPC, CPMA, CEMC

  3. #3
    Longmont Colorado
    "denied" seems pretty weak to me as well. It needs to be clear that the physician queried the patient about their history and I don't think that this example suffices.
    Brad Howard, CPC, AHIMA Approved ICD-10 CM/PCS Trainer
    McKesson Specialty Health

  4. Default
    Thank you!..also would it make a difference from 95 and 97 guidelines??

  5. Default
    I agree with the previous responses. If the patient refused or the Physician was unable to obtain hx due to the patients condition (must explain pt's condition, unresponsive, dementia, etc.), then these types of statements would be acceptable. This applies to both 95 & 97 guidelines.

    Hope this helps!!!

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