tci E/M Coding Alert - 2020 Issue Q3

Reader Questions: Expand This Documentation of Family History

Question: Our provider documented “No sick contacts.” Would this be enough to fulfill the family history portion of an E/M service? Iowa Subscriber Answer: CPT® defines “family history” as a review of medical events in the patient’s family that includes significant information about: The health status or cause of death of parents, siblings, and children Specific diseases related to problems identified in the chief complaint or history of the present illness, and/ or system review Diseases of family members that may be hereditary or place the patient at risk Typically, family history is more along...

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