ED Coding and Reimbursement Alert

Question: Would you consider “No sick contacts” acceptable for Family History?

Wisconsin Subscriber

Answer: CPT® defines Family History as a review of medical events in the patient’s family that includes significant information about:

• The health status or cause of death of parents, siblings, and children
• Specific diseases related to problems identified in the Chief Complaint or History of the Present Illness, and/or System Review
• Diseases of family members that may be hereditary or place the patient at risk

Typically family history is more along the lines of heart disease, diabetes etc. Immediate contacts could also be co-workers, roommates, classmates or anyone the patient has come in contact with that had a medical impact on their presenting problem, which sounds more like a social history. Exercise caution about using the phrase “no sick contacts” as a macro option in an electronic medical record.