tci Part B Insider - 2012 Issue 2

Reader Question: 'None' May Not Be Good Enough Answer When Recording Family History

Question: Our physician often records the word "none" under the "family history" section of his E/M notes for a privately-insured patient. To me, that isn't comprehensive enough for me to count as being completed, but the physician disagrees. In my opinion, it would only count if the doctor recorded something more along the lines of "none that relate to the present illness/injury." Can you advise? Delaware SubscriberAnswer: The answer comes down to the auditing rules that your payer maintains, but most consultants agree that they would only give credit for "none" toward family history if the condition was...

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