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E/M History Clarifications

Created: 05/27/2015 | Updated:  
ACE would like to provide some clarification on common questions regarding the history section of E/M visits for billing purposes:

• The verbiage “None” or “Not on file” is not acceptable, and will not count as billing credit for any part of the PFSH.
• The verbiage “Non-contributory” or “Not-pertinent” will be acceptable for Family History only. However, the provider should be educated that the recommendation is to document what the family history non-contributory or not pertinent is for (e.g., Family history non-pertinent/non-contributory for heart disease for a patient complaining of chest pain.)
• If the provider is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining history (if this is documented, this will count as billing credit towards a comprehensive history).
• If the provider is referencing a past note for ROS and/or PFSH, the note does not necessarily have to state the date of the note they are referencing. However, the documentation should direct you to the past note. If it is not clear, you may query the provider for clarification.