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EMR/EHR documentation

Our providers have started using canned text for PFSH. We are not sure why but are questioning the validity of this text.

"Past medical, surgical, and family histories reviewed for relevance to current acute and chronic problems."

We clinic coders do not feel this is sufficient documentation. Any thoughts on this?

For example if patient is in for colon screening with no personal history of issues and the above statement is all we get, we cannot determine if there is a family history and may receive a denial.

Thank you
Corenna CPC

Medical Billing and Coding Forum