Pulmonology Coding Alert

Question: Our pulmonologist documented “No sick contacts.” Would this be enough to fulfill the family history portion of an E/M service?

Oklahoma 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 an overarching option in a medical record, particularly as a potential macro in an electronic health record (EHR).