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Can this be counted for PFSH

  1. #1
    Default Can this be counted for PFSH
    Medical Coding Books
    Family History was reviewed and was noncontributory.

    Thanks for any and all responses

  2. #2
    Location
    North Carolina
    Posts
    3,126
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    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?

    Answer:
    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).

    Resource(s):

    E/M Documentation Guidelines



    last updated on 12/14/2011


    http://www.palmettogba.com/palmetto/...navmenu=%7C%7C

  3. #3
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    Thanks

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    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
    Location
    Swainsboro/Statesboro
    Posts
    671
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    I would count it as well because he did mention that he asked and it is non contributory.

    thanks, Sue
    Susan Edwards, CPC, CEDC
    smecoder@gmail.com

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