A few questions were raised after the last post, I've included this for everyone's benefit.
Q: What do you suggest for Family History when the Family History is unrelated to the patient's problem?
A: Medicare likes the PMFSH (Past Medical/Family/Social History) section to be as specific as possible. So, statements like "No Significant Family History" are not adequate. Strictly from a billing standpoint, documenting unrelated family history counts. A medico-legally sound approach to family history is to document pertinent negatives. For example, for headache patients documenting "No family history of aneurysm" is not only billable, but medico-legally sound. Another example would be for chest pain patients. Documenting " No family history of early CAD, MI, TAD" is billable and is an excellent way to document your risk stratification analysis.
Q: What about documenting under PMFSH - "Please refer to HPI." Is this ok?
A: Technically it is adequate IF you actually include PMFSH in the HPI. I have seen "Please refer to HPI" used but no mention of a patient's past medical or social history is actually included in the HPI. That DOES NOT COUNT. Remember: you want to make the job as easy as possible for the billers to not inappropriately down code your chart. My personal preference is to not use "Please refer to HPI" and document in the designated sections to assist with billing. It's still ok to include past medical history in the HPI, however.
Q: I'm confused, I thought you said "Negative" was allowed!
A: Nope! You are mistaken. "Negative" "Non-Contributory" "No Significant PMHx" "None" "Denies" "Reviewed in chart" are not adequate phrases. It's an easy fix: make a macro that says "No Past Medical History"
Coming up: Top 5 documenting foils!
Disclaimer: Information contained in this blog is the opinion of the author and does not necessarily reflect the official opinion of Carolinas HealthCare System. Application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.