Part B Insider - 2020 Issue 2
Reader Question: Know What Classifies As “Family History”
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Article Overview
This article addresses a reader question about whether a brief statement in the medical record is sufficient for the family history portion of an evaluation and management history. It is written for coders and other revenue cycle professionals who review documentation for history elements and need a general understanding of how CPT® describes family history versus other history categories.
Why This Topic Matters
Accurate interpretation of history documentation affects E/M chart review and documentation completeness. The article helps readers recognize the broad scope of family history so they can better assess whether a note supports the intended history component.
What You Will Learn
- How CPT® frames the family history component of E/M history
- Which broad types of information are considered part of family history documentation
- Why certain wording in a chart may be better aligned with another history category
- Documentation cautions relevant to electronic medical record phrasing
Who Should Read This
- Medical coders
- Auditors
- Compliance staff
- Revenue cycle professionals
- Clinicians documenting E/M services
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