READER QUESTIONS: Avoid This No-Credit History Statement

Question: If an internist marks a Medicare patient’s history element as “noncontributory,” should I count the notation toward FH?


Michigan Subscriber

Answer: No. Medicare auditors will not give credit for a history element that a physician documents as “noncontributory.” The term implies that the physician thought it was not necessary to ask a patient about that item.

Better way: Encourage the allergist to record something specific about the patient’s family history (FH). Compare these two hospital admission notes for a 14-year-old patient who presented to the emergency department with an asthmatic attack:

Chart 1: “The patient is 14 years old, presented to the emergency department for asthma. Family history is noncontributory.”

Chart 2: “The patient has no family history of asthma.”

Although both notations indicate that a family history of asthma plays no role in the patient’s condition, only the allergist who wrote chart 2 should receive credit for the element under FH.

Instead of offering information, chart 1 implies that the physician thought the patient’s status was unimportant and therefore did not inquire about it. Actually, the physician is saying, “It does not matter whether this patient’s mother and father have asthma or not. This patient has it, and this is the first time he is coming in with a suggestion that he has some sort of asthmaticus.”

In contrast, chart 2 offers concrete information about the patient’s history and therefore shows that the allergist inquired about this area. Other acceptable notations include statements such as “father has occasional asthmatic attacks” or “mother has no history of asthma.”

Do this: Follow the same rule for review of systems, social history, and past history--if the internist documents “noncontributory,” do not give him credit for the statement.