"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.
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Department of Emergency Medicine
Medical Education Building., Third floor
1000 Blythe Blvd.
Charlotte, NC 28203