Primary Care Coding Alert

Question: If a family physician 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 unnecessary to ask a patient about that item.

Caution: Many doctors use the term -noncontributory- interchangeably with the word -negative.- This means that the history collected does not apply to the current problem. It could also mean that there was no history to collect.
 
Some doctors use -noncontributory- to actually mean the history is not contributing to the illness. So it can be confusing, and physicians should either document the history or document that the history collected is negative.

Better way: Encourage the family physician to record something specific about the patient's family history (FH) when appropriate. Compare these two hospital admission notes for an 85-year-old patient who presented to the emergency department for chest pain:

Chart 1: -The patient is 85 years old, presented to the emergency department for chest pain. Family history is noncontributory.-

Chart 2: -The patient has no family history of early coronary disease.-

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

Instead of offering any relevant positive or pertinent negative information, chart 1 implies that the physician thought the patient's FH status was unimportant and therefore did not ask about it.

Actually, the physician is saying, -It does not matter if this patient's mother and father are still alive or not. This patient lived into his mid- or high 80s, and this is the first time he is coming in with a suggestion that he has some sort of coronary disease.-

In contrast, chart 2 offers concrete information about the patient's history and therefore shows that the physician asked about this area. Other acceptable notations include statements such as -Father died at 50 of a stroke- or -Mother is alive and well.-

Do this: Follow the same rule for review of systems (ROS), social history (SH), past history (PH)--if the physician documents -noncontributory,- do not give him credit for the statement.