Medicare Compliance & Reimbursement
No Family History? Explain Why
It happens from time to time — you’re filling out a thorough E/M record, but you’re unable to complete the family history section, often because the patient doesn’t know her history. The solution, Part B MACs advise, is to document the fact that you tried to get the information but couldn’t — and record the reason.
“If for some reason you cannot obtain the family history, the documentation must support the reason why (e.g., the patient was adopted,” says Part B MAC Palmetto GBA in its “Frequently Asked Questions” page.
You should not write “noncontributory, unremarkable or negative” in the family history section, because that does not help an auditor understand what was addressed or even which questions you asked the patient, Palmetto says.
Resource: For more on this topic, visit www.palmettogba.com/palmetto/providers.nsf/DocsCat/Jurisdiction-11-Part-B~8EEM6K6862
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