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Family History - Is this correct?

  1. #1
    Default Family History - Is this correct?
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    I know that I have read this somewhere but can't think of where. A doctor is dictating his H&P for the initial hosptial care 99222 and states the family history as non-contributory or unremarkable. I do not count this as there should always have some family history. Is this correct? any help with this is appreciated. Lynn

  2. #2

    When the terms "non-contributory" or "negative" are used in PFSH documentation, the documentation might indicate "Past medical history is non-contributory" or "Social history is non-contributory." Such documentation would not indicate the provider had actually addressed the issues. It must be clear that the PFSH was discussed with the patient. To use the term "non-contributory" alone does not clearly indicate PFSH was addressed.

    I hope this helps

    Ivonne C., CPMA

  3. #3
    yes, when a DR only states that, it cannot count.

  4. #4
    Medical Billing
    Thanks everyone. I found the information I had read after posting this and now feel like a real goof. You know sometimes you read so much stuff and then it all gets jumbled and let's face it: I'm old and have cataracts!!! That's my story and I am sticking to it. Lynn

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