Part B Insider - 2015 Issue 2
Reader Question: Do You Have to Be Family to Count as Family History?
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Article Overview
This article addresses a common documentation question about whether a statement about sick contacts belongs in family history. It explains the general CPT framework for family history and discusses how related history language may overlap with social history in clinical documentation. The piece is aimed at coders, auditors, and clinical documentation staff who review history sections for accuracy and appropriate categorization.
Why This Topic Matters
Accurate history classification affects documentation quality, coding support, and audit readiness. The article helps readers recognize when broad, non-family exposure language may not fit the family history category and why wording choices in electronic records matter.
What You Will Learn
- How family history is generally defined in coding guidance
- How history statements related to contacts may be viewed in documentation review
- Why wording choices in electronic medical records can matter for history classification
- How family history can relate to hereditary risk and conditions in close relatives
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation specialists
- Physician office staff
- Health information management professionals
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