Medicare Compliance & Reimbursement - 2020 Issue 8
Reader Questions: Expand This Documentation of Family History
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Article Overview
This reader Q&A explains how family history is treated in evaluation and management documentation and why wording in the medical record matters. It is aimed at coders, auditors, clinicians, and compliance staff who review history elements and documentation support. The article covers the general categories of family history, the distinction between family and social history concepts, and caution around shorthand language in electronic health records.
Why This Topic Matters
Accurate history documentation can affect whether the record supports the intended E/M service level and can reduce ambiguity during audits or record review.
What You Will Learn
- How family history is generally understood in E/M documentation
- Which broad types of information are typically considered part of family history
- Why some contact-related wording may align more closely with social history
- Why concise EHR phrasing should be used carefully in documentation
Who Should Read This
- Medical coders
- Coding auditors
- Physicians and other clinicians
- Compliance staff
- Revenue cycle professionals
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