This has to be the worst social history ever. Everyone knows that in order to get paid under the evaluation and management rules (E/M medical coding) of the Medicare National Bank, the more nonsense information you obtain, the more you get paid. Does it meet Medicare medical necessity? Of course it does. It always does. If you want to make sure you can collect the charge for a 99223 (here's a secondary look at 99223) instead of a 99221 and not be accused of fraud, you have to make sure you have a social history component.
So what do you do for your history and physical examination documentation for hospital admission dictations? You write something, anything, just to meet the compononent requirements for the E/M, even if you think it has no bearing on the care plan going forward. There is nothing anywhere that clarifies when a social history is not indicated. It will always be indicated. And to get paid, you have to include it. That's why doctors document it. I would much rather just move on to more important things when social history doesn't matter. But the Medicare National Bank makes it matter, every time.
That's the way E/M roles. So what did the worst social history ever look like? It was done by an APRN in a small town out yonder.
Patient presents with her daughter.
I don't know what they're teaching in nursing school these days or if taking a social history is even a nursing education requirement. It's obviously not an APRN requirement.
That's not even a social history. That's an observation. It's not even history. It describes the present. If you want to make it appear like you at least applied some effort, say that the patient was drinking or smoking with her daughter. Now that's a social history worth documenting, if there is such a thing.
What's the worst thing you've ever seen documented for social history?
