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Can I use this for Family history?

  1. #1
    Default Can I use this for Family history?
    Medical Coding Books
    Patient present with fever and flu like symptoms. The note says that he lives with wife and 2 kids and they are well.

    Is that family history?

  2. #2
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    I may be in the minority here, but I would say this is social history. Living arrangements is social history. Just my two cents here!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  3. #3
    Default
    I agree, social history.
    Anna Weaver, CPC, CPMA, CEMC
    Associate Auditor

  4. #4
    Default
    The argument we have is that he lives with his kids and they are well..as in not sick with the flu like symptoms he has..

    knowing that would you still say social? Anyone else. I would like to get a good number of responses on this..majority rules, lol

  5. #5
    Default
    I always think of family history as just that-history, such as mom is alive at 70 years and has diabetes, dad deceased coronary failure. No siblings.

    I don't usually see the fact that they don't have the same symptoms as he does as family history.

    Now, if they said something about the kids and whether they have any conditions/diseases and such, then that would count as family history.
    Anna Weaver, CPC, CPMA, CEMC
    Associate Auditor

  6. #6
    Default
    Still social.

    Family history is more your chronic/congential type issues, not acute communicable sickness.

    There is no difference in saying wife (not family-social) and kids not sick than saying no one at work is sick. These are your social contacts, you just also happen to be related to some of them!

    Laura, CPC, CPMA, CEMC

  7. #7
    Location
    Greeley, Colorado
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    2,045
    Default Agree
    I agree with the others - social history.
    Family history would be those that are related by blood and have potential hereditary or congenital diseases. You do mention children, but they are well. If it stated that one of the children had, let's say, diabetes then that could be family history.
    Lisa Bledsoe, CPC, CPMA

  8. #8
    Location
    Milwaukee WI
    Posts
    4,466
    Default Disagree - in general / Agree in specific
    I agree in this specific case because stating "they are well" just is not specific enough.

    But I disagree that family history has to be only about chronic and/or hereditary illnesses. Family history can be highly specific to the presenting problem. So if the physician had stated that the kids also had flu-like symptoms. Or even stated specifically that no other family members have flu-like symptoms I would count it as family history. (I do not mean to imply that it wouldn't also be beneficial to know if there was a family history of diabetes or HTN or MI or cancer.)

    That being said ... if this is an established patient the argument is moot. You only need 1 area of PMFSH (plus 4 elements of HPI and at least 2 of ROS) to qualifiy for a detailed history. I cannot imagine that you plan to code a 99215 visit for fever and flu. If it is a new patient you would need all three areas of PMFSH only if you wanted to code a 99204 or 99205 (where you would also need a comprehensive exam and either moderate or high MDM ... can't really envision medical necessity for fever & flu.)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 02-12-2010 at 05:27 PM.

  9. #9
    Location
    Greeley, Colorado
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    2,045
    Exclamation
    Good point Tessa. I just looked at my audit tool and under family history it states "a review of medical events in the patient's family, including disease which may be hereditary or place the patient at risk". So this could be counted as family history IF the children were sick - therefore putting the patient at risk.
    Lisa Bledsoe, CPC, CPMA

  10. #10
    Location
    Milwaukee WI
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    4,466
    Default It would be family whether they were sick or not
    Pertinent negatives count in the history section... including PMFSH.

    It would still be family history even if no one else in the family was recently ill with same/similar symptoms/disease. The deciding factor would be questioning the history of possible exposure/risk to patient from family members.

    A patient who presents with fever and flu-like symptoms may (or may not) have been exposed by family members. So it would be a relevant family history to state - specifically - whether (or not) any family members have had same/similar symptoms.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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