EM Coding Alert

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 pediatrician recorded something more along the lines of “none that relate to the present illness/injury.” Can you advise?

Oklahoma Subscriber

Answer: 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 specified to indicate that “none” pertains to a specific history for which information had been provided.

For instance, if the patient was being seen for a fast heartbeat, the doctor might record, “The patient reports no family history of cardiovascular disease.” This demonstrates that a family history was performed, but the patient didn’t report anything related to the visit. If the doctor simply records “none,” it’s unclear whether he actually performed the history.