# Family History - Is this correct?



## Lkimsey (Dec 13, 2010)

I know that I have read this somewhere but can't think of where.  A doctor is dictating his H&P for the initial hosptial care 99222 and states the family history as non-contributory or unremarkable.  I do not count this as there should always have some family history.  Is this correct?  any help with this is appreciated.  Lynn


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## Ivonne C. (Dec 13, 2010)

http://www.wpsmedicare.com/part_b/publications/em_history.shtml

When the terms "non-contributory" or "negative" are used in PFSH documentation, the documentation might indicate "Past medical history is non-contributory" or "Social history is non-contributory." Such documentation would not indicate the provider had actually addressed the issues. It must be clear that the PFSH was discussed with the patient. To use the term "non-contributory" alone does not clearly indicate PFSH was addressed.


I hope this helps 

Ivonne C., CPMA


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## jettagirlfl (Dec 15, 2010)

yes, when a DR only states that, it cannot count.


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## Lkimsey (Dec 21, 2010)

Thanks everyone.  I found the information I had read after posting this and now feel like a real goof.  You know sometimes you read so much stuff and then it all gets jumbled and let's face it:  I'm old and have cataracts!!!  That's my story and I am sticking to it.  Lynn


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