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Family History or Not

  1. #1
    Overland Park, KS
    Default Family History or Not
    Medical Coding Books
    If under family history the provider writes, "No significant medical illnessess in the past," would you count this as family history?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

  2. #2
    Default Gray area.
    It doesn't state "WHO" is healthy to relate the statement to multiple family members. According to the 95 DGs:

    "Family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk)".

    My audit software (Intelicode) is even more specific as to say parents, siblings, etc.

    If it is the sole determining factor for code selection I might allow it, but I would definitely counsel the provider to be more specific.

    The goal in obtaining family history is to determine genetic predisposition to certain diseases. That statement just doesn't do that for me.

  3. #3
    Overland Park, KS
    My thoughts exactly. Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

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