"Negative" or "No Significant Past Medical History" are not acceptable phrases for Medicare billing for Past Medical History/Surgical History/Family Hisotry/Social History.
BAD: No Significant Past Medical History
BAD: Not Significant
BAD: Reviewed in Chart
GOOD: Denies Past Medical History
GOOD: No Past Medical History
GOOD: See HPI / See Problem List ** (caveat: you must reference PMHx in the history, avoid the word significant)
Specific TIME is an important component of critical care billing.
BAD: 30-74 minutes of critical care performed
GOOD: In excess of 30 minutes of critical care performed
GOOD: x Minutes of critical care performed
GOOD: In excess of 74 minutes of critical care performed
Don't Forget: to add "excluding teaching time or time performing procedures"
That's a wrap folks. We are doing better but I have seen SEVERAL slip ups on the past medical history issue.
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.