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History unchanged ....

  1. Default History unchanged ....
    Medical Coding Books
    If a physician states family hx unchanged from previous visit---is this acceptable? I know that it must state "family hx unchanged since {insert date} but, ..........???????

    ...darn doctors for trying to take short cuts all the time


  2. #2
    North Carolina
    You are on the right path...If my physicians choose to document this way, then I always refer to this section of the "DG's". I've taken a few, scrubbed, examples to E/M workshops and the Medicare guru's state we are in compliance.

    DG: A ROS and/or a PFSH obtained during an earlier encounter does not
    need to be re-recorded if there is evidence that the physician reviewed
    and updated the previous information. This may occur when a
    physician updates his or her own record or in an institutional setting or
    group practice where many physicians use a common record. The
    review and update may be documented by:
    describing any new ROS and/or PFSH information or noting
    there has been no change in the information; and
    noting the date and location of the earlier ROS and/or PFSH.
    Rebecca CPC, CPMA, CEMC

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