kte01A asks: So are we saying "family history negative" is acceptable or unaccepable?
Negative for what?
It only takes a half a second to say what the history is negative for ...
"Family history negative for problems with anesthesia or bleeding disorders" is the most frequent one I see our surgeons use on their H&Ps.
No one wants to pay for services that were not provided - Medicare, Medicaid, commercial insurances. I've shadowed my docs in clinic and I KNOW they are asking these questions, but they don't always document it! As I tell my docs, the only proof I have that you did something is if you have written it down, signed and dated it. And that's the only proof I can submit to the carrier who questions the level of service.
If you provided the service and want to code the correct level, then document to that level.
Okay ... off my soap box now ... I would probably count the statement "Family history is negative" ... but I'd try to educate the doctor to be more specific with some gentle nagging (and nagging, and nagging).
I hope that helps,
F Tessa Bartels, CPC, CEMC
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