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ED Coding and Reimbursement Alert

Reader Questions:

Say No to 'Past History Negative'

Published on Sun Sep 19, 2004

Question: When the physician writes "past history is negative," would this satisfy the "past history" element when deciding the extent of the history portion of the evaluation and management code? The guidelines state that "at least one specific item from any of the three history areas must be documented for a pertinent PFSH."
    
New Hampshire Subscriber
 
Answer: You are correct that the physician should document at least one item from one of the three areas: past medical, family, or social history. Expanding the phrase in question to "past history negative for asthma" - or whatever the presenting problem - is appropriate.
 
Auditors may interpret "past history negative" as meaning no history was indicated or taken, so make sure the physician knows to document an element.
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