Documenting Family History for New Patient Visits

Documenting Family History for New Patient Visits

October 29, 2020

Question:
I’ve heard that all you need to document for family history is the word “none”, and that would count as documenting. Is this enough?

Answer:
No. Documenting “none” is saying that the patient does not have a family history, and this would not be accurate as we all have a family history. If the patient does not know the family history, you can say “noncontributory” as long as you state the reason it was not documented. For example, the patient “was adopted with no knowledge of family history” or the “patient has dementia and no caregiver is present to relate family history”. And, don’t forget that the documentation of Family History is not considered for an office visit code choice starting 1/1/21. Click here for more information about our webinars.

*This response is based on the best information available as of 10/29/20.

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