Wiki Family History - Can I accept that

[nyyankees]

doc states "no significant family history" in note. Can I accept that or does there need to be an example as in Hx of cancer? Thanks.

 

[Nihema12]

Family History

Good Morning, I'm new to the, AAPC website this is my first time replying to any messages, but I hope that my information helps. Your provider should take a family history of disease into account when treating patients especially for those patients that need to be treated for cancer, diabetes and heart disease and a pregnant mother concerned with prenatal care and possible genetics. This plan of action will determine risk and your provider would be able to take the appropriate plan of action more on an individual basis.

If the provider stated " No Significant Family History" I would ask him to elaborate so that way you can be able to make an informative decision. The patient probaly do have a family history of some illness and may not have shared it with the provider. So I would ask again just to make sure that he understands the importance of having this information, if he still indicates the same response, I would not worry about it. aslong as he has it documented in the notes you should be okay.

 

[Tonyj]

doc states "no significant family history" in note. Can I accept that or does there need to be an example as in Hx of cancer? Thanks.

Our MAC is Novitas Solutions Inc and this is a quote from their Q/A section;

Under limited circumstances, could the term “noncontributory” be used as appropriate documentation to support the review of systems (ROS) and family history sections of the history component of an evaluation and management service (E/M)?

The term "noncontributory" may also be appropriate documentation when referring to a patient's family history during an E/M visit, if the family history is not pertinent to the presenting problem.

Hope this helps

 

[MikeEnos]

NHIC has a similar answer, they accept "noncontributory" for Family History:

Question 7. Can I say “non-contributory” when completing the FH if the information obtained
is not germane to the clinical problems at hand?

Answer 7. Family history becomes important if the nature of the chief complaint(s) /
symptom(s) on the date of service is such that a family history would be relevant. To Medical
Review, the word "noncontributory" is a value judgment, meaning that there is an inference that
the provider did give family history some consideration in order to decide it was not relevant.
As reviewers, credit is given to all areas that are considered and documented by the provider.
Our medical review team prefers providers stay away from this terminology.