tci E/M Coding Alert - 2013 Issue 4

Reader Question: Get Specific with Family History Notations

Question: Our physician often records the word “none” under the “family history” section of his E/M notes for a privately-insured patient. To me, that isn’t comprehensive enough for me to count as being completed, but the physician disagrees. In my opinion, it would only count if the pediatrician recorded something more along the lines of “none that relate to the present illness/injury.” Can you advise? Oklahoma Subscriber Answer: The answer comes down to the auditing rules that your payer maintains, but most consultants agree that they would only give credit for “none” toward...

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