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Thread: Can this be counted for PFSH

  1. #1
    Join Date
    Apr 2007
    New Orleans

    Default Can this be counted for PFSH

    AAPC: Back to School
    Family History was reviewed and was noncontributory.

    Thanks for any and all responses

  2. #2
    Join Date
    Apr 2007
    North Carolina


    Quote Originally Posted by perkins05 View Post
    Family History was reviewed and was noncontributory.

    Thanks for any and all responses
    Typically, carriers do not accept this statement.

    Is it acceptable to use 'noncontributory, unremarkable or negative' when reporting past, family or social history?

    No, because the statement 'noncontributory, unremarkable or negative' does not indicate what was addressed. Did the nurse or physician ask specific conditions (i.e., any family history of coronary artery disease)? If for some reason you cannot obtain the family history, the documentation must support the reason why (e.g., the patient was adopted).


    E/M Documentation Guidelines

    last updated on 12/14/2011


  3. #3
    Join Date
    Apr 2007
    New Orleans



  4. #4
    Join Date
    Apr 2007
    Milwaukee WI

    Default Family History was Reviewed

    On the other hand ....

    The provider does state that the family history was reviewed. So I would be tempted to count it, especially if I found any evidence of a questionaire completed by patient.

    HOWEVER ... if the documentation read: Family History noncontributory ... I would NOT count it, because I'd have no way of knowing whether it was reviewed at all.

    The BEST way to avoid this controversy is for the physician to get in the habit of being specific: Family history negative for any related diseases or syndromes.

    Even with trauma I've trained my surgeons to ask and document family history of problems with anesthesia or bleeding issues. THAT is relevant to the proposed surgical intervention.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. #5
    Join Date
    Apr 2007


    I would count it as well because he did mention that he asked and it is non contributory.

    thanks, Sue
    Susan Edwards, CPC, CEDC

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