Wiki Pfsh - New outpatient office visit

[soprano]

New outpatient office visit, physician has HIGH COMPLEXITY MDM and therefore wants to document a comprehensive exam. If there is no family hx of any disease, what can he say so that he will get credit for a complete PFSH? Can he say "family hx is negative or "there is no family hx on file" and still get credit for a complete PFSH? Please advise.

Thank you in advance.

 

[sullivak]

Yes and no. He gets credit for documenting negative findings as well as positive findings, but I would expect more specific documentation than this. "Family hx is negative" is iffy - I would want to know what about the family history the physician asked. For instance, if the patient is in the office for chest pain, and the doc says family hx is negative for heart disease (or other diseases), that would be more specific and should count.
I definitely would not count "there is no family hx on file". This sounds like something auto-generated by an EHR, and if there is no "history on file" why didn't the physician get a family history from the patient? This is a component of the office visit that the physician is supposed to consider/collect, not only a document that a patient fills out in the waiting room. By the way, the physician is supposed to look at and sign off on those history documents the patient fills out too.
Hope that helped some.