General Surgery Coding Alert - 2013 Issue 4
Reader Question: Get Specific with Family History Notations
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Article Overview
This reader question addresses documentation expectations for family history in evaluation and management notes and how auditors may interpret brief notations in a privately insured setting. It is aimed at physicians, coders, auditors, and compliance staff who need to understand the general documentation standards that affect whether a history element is considered complete.
Why This Topic Matters
Documentation wording can affect audit outcomes and whether a history component is credited in an encounter note. The article helps readers understand why specificity in family history documentation may matter for compliance review.
What You Will Learn
- How family history documentation may be viewed during E/M auditing
- Why brief or generic history notation can create ambiguity
- How payer auditing practices can influence documentation review
- What kinds of family history wording are generally considered more specific
Who Should Read This
- Physicians
- Pediatricians
- Medical coders
- Medical auditors
- Compliance staff
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