Part B Insider - 2017 Issue 1
You Be the Coder: Decode Social History For Newborns
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Article Overview
This premium coding Q&A focuses on social history documentation for newborns in the context of evaluation and management (E/M) history requirements. It is aimed at coders, compliance staff, and clinicians who document histories for infant patients and need to understand the general categories of information that can support a newborn social history. The article discusses the broad framework of past, family, and social history and the types of non-clinical household and caregiver context that may be considered.
Why This Topic Matters
Accurate history documentation is important for E/M reporting and for making newborn records more complete and compliant. This article helps readers recognize the kinds of social-context information that are typically relevant for an infant, reducing documentation gaps and confusion.
What You Will Learn
- How social history fits into the past, family, and social history framework for E/M services.
- What broad categories of information may be considered when documenting a newborn’s social history.
- How documentation for newborns can incorporate parent or caregiver context.
- Why age-appropriate history documentation matters for evaluation and management records.
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physicians
- Nurse practitioners
- Physician assistants
- Medical documentation specialists
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