Heidi Posted Mon 17th of June, 2019 12:41:32 PM
I have a physicians when they do their initial visit at hospital they always put for family history reviewed and non contributory I was taught we can not use reviewed alone nor non contributory alone but is this acceptable or not to count as part of e/m?
SuperCoder Answered Tue 18th of June, 2019 08:32:32 AM
Thank you for your question.
Family history includes a review of medical events, diseases, and hereditary conditions that may place the patient at risk.
Most of Medicare administrative contractors (MACs) and some private payers have stated that “noncontributory” is not sufficient for documentation of the family history.
For initial visit, provider need to have the family history marked on the E/M in PFSH section.
The term ‘noncontributory’ may be appropriate documentation when referring to a patient’s family history during an evaluation and management visit, if the family history is not pertinent to the presenting problem.”
Remember that for established patients, when provider make no changes to the family history obtained at prior encounters, it is sufficient to document that fact (e.g. family history – reviewed, no change from MM/DD/YYYY).
Hope that helps.
Heidi Posted Tue 18th of June, 2019 11:35:49 AM
so if i am reading correctly the above information for the initial visit it can state reviewed and noncontributory as long as it includes "in this setting / present setting or not pertinent to the present problem" or wording like that but not just "reviewed and noncontributory "is that correct ?
SuperCoder Answered Wed 19th of June, 2019 09:37:27 AM
It would depend on payer to payer scenario. Some payers may require the findings of family history whereas some may consider non-contributory as sufficient documentation. Kindly check the guidelines related to PFSH in your area/locality and bill accordingly.