Cardiology Coding Alert

Hint: Make sure you know the difference between pertinent and complete PFSH.

When it comes to correctly determining the level of an evaluation and management (E/M) visit for patients in your cardiology practice, documenting the patient’s past medical, family, and social history (PFSH) is vital. And, if the medical documentation isn’t clean and concise, you could risk miscoding your cardiologist’s E/M services.

Answer the following FAQs to make sure you always know what’s going on with a patient’s PFSH.

Put Together the Different Pieces of PFSH

FAQ 1: What different pieces of information constitute a patient’s PFSH?

Answer: When talking about history in a coding sense, we’re actually talking about three distinct and different aspects, past medical, family, and social history, of a patient’s life prior to encountering your provider.

Past medical history: This is “a review of the patient’s past experiences with illnesses, injuries, and treatments that includes significant information about:

• “Prior major illnesses and injuries
• “Prior operations
• “Prior hospitalizations
• “Current medications
• “Allergies [eg, drug, food]
• “Age-appropriate immunization status
• Age-appropriate feeding/dietary status.”

Family history: According to CPT^® guidelines, a family history is “a review of medical events in the patient’s family that includes significant information about:

• “The health status or cause of death of parents, siblings, and children;
• “Specific diseases related to problems recognized in the Chief Complaint [CC] or History of the Present Illness [HPI], and/or System Review [ROS]
• “Diseases of family members that may be hereditary or put the patient at risk.”

“It [family history] really is a list of conditions and diseases that family members have or reasons for death,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. “However, it’s worth mentioning that it might also be reasonable to document that the patient’s family history is unknown if they are adopted or estranged from family.”

Social history: This history is “an age appropriate review of past and current activities that includes significant information about:

• “Marital status and/or living arrangements
• “Current employment
• “Occupational history
• “Military history
• “Use of drugs, alcohol, and tobacco
• “Level of education
• “Sexual history
• “Other relevant social factors.”

Two of the most commonly documented social history elements are tobacco and alcohol use, according to Bucknam. Social history is also the correct place to include work/ retirement, hobbies, school, and other factors about the patient’s life.

Know the Difference Between Pertinent Versus Complete PFSH

FAQ 2: What are the two types of PFSH?

Answer: There are two kinds of PFSH — pertinent and complete.

“A pertinent PFSH is a review of at least one of the history areas directly related to the problem identified in the HPI, whereas a complete PFSH is of a review of two or all three of the PFSH history areas,” explains Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Coding caution:  You’ll need all three PFSH elements when the E/M service requires a “comprehensive assessment or reassessment of the patient,” according to CMS. For all other E/M service levels that require a comprehensive history, you only need to document two areas (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf). The E/M documentation guidelines specify which categories of E/M services require

Observe This Bucket Analogy for PFSH Clarity

FAQ 3: I still don’t completely understand the differences between pertinent versus complete PFSH. Can you help me?

Answer: To better understand the differences between pertinent and complete PFSH, take a look at this bucket analogy from Laureen Jandroep, CPC, COC, CPC-I, CPPM, founder/CEO Certification Coaching Organization, LLC in Oceanville, New Jersey.

“Think of your P, F, and S as each being a bucket that you are trying to fill. As soon as you have one documentation item in a bucket, you are finished with the bucket. You cannot have the same documentation item in two buckets.

“If you have one bucket, then you have a pertinent PFSH. If you have two or three buckets filled, then you have a complete PFSH.

“Usually if the overall EM sub-category requires three bullets for the history, exam, and medical decision making, then you will need to have a complete PFSH.

“On the other hand, if the overall EM sub-category requires two of three bullets (and ER visits), then you will only need a pertinent PFSH.

“Some sub-categories like subsequent hospital, follow-up inpatient consultations, and subsequent nursing facility care, require no PFSH.”

Get Why Understanding 2 Types of PFSH is Important

FAQ 4: Why is understanding the distinction between pertinent and complete PFSH so important?

Answer: “The distinction between pertinent and complete PFSH is important because it relates to the level of history that is supported by the documentation, which, in turn, may impact the level of E/M code supported by the documentation,” according to Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. For example, to support a level of 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity ...) for a new patient, or 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity …) for an established patient (if history is one of the three components on which you’re basing your code selection), “you will need a pertinent PFSH, which is a required element for a detailed history,” Moore reminds coders.

In order to code the highest E/M levels for new patients (99204 and 99205) and the highest level for an established patient (99215), however, you will need to document a comprehensive history. For that, you will need a complete PFSH.