tci Medicare Compliance & Reimbursement - 2015 Issue 12

Industry Notes: No Family History? Explain Why

It happens from time to time — you’re filling out a thorough E/M record, but you’re unable to complete the family history section, often because the patient doesn’t know her history. The solution, Part B MACs advise, is to document the fact that you tried to get the information but couldn’t — and record the reason. “If for some reason you cannot obtain the family history, the documentation must support the reason why (e.g., the patient was adopted,” says Part B MAC Palmetto GBA in its “Frequently Asked Questions” page. You...

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