General Surgery Coding Alert - 2012 Issue 2
Reader Question: 'None' May Not Be Good Enough Answer When Recording Family History
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Article Overview
This article discusses a documentation question for evaluation and management notes, focusing on whether a simple family history entry is sufficient for audit purposes. It is aimed at coders, auditors, and clinical documentation staff who need to understand how payer audit expectations can affect history completeness. The guidance is framed at a high level and addresses documentation clarity rather than code selection.
Why This Topic Matters
Family history documentation can affect whether an E/M history element is considered complete during review. Understanding payer audit expectations helps reduce documentation ambiguity and supports more consistent chart review.
What You Will Learn
- How family history documentation may be reviewed in an E/M note
- Why ambiguity in history entries can matter during audits
- How payer-specific auditing expectations influence documentation review
- What types of wording may make a family history entry clearer in general terms
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement staff
- Physician office staff
- Practice managers
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