Cardiology Coding Alert

Question:

Is it OK if the physician reviews a previous PMFSH instead of taking a new one?

New York Subscriber

Answer:

Based on E/M guidelines, if a patient’s past medical, family, and social history (PMFSH) has not changed since a prior visit, your provider doesn’t have to document the information again. He does, however, need to document that he reviewed the previous information to ensure it’s up to date and also note in the present encounter’s documentation the date and location of the earlier acquisition of the PMFSH. Some payers will give no PMFSH credit if you overlook one of these criteria.

There are three levels of PMFSH: none, pertinent, and complete.

None: If your provider does not document any PMFSH elements, you can reach only an extended problem-focused level of history. That means the highest codes you’ll be able to report are a level-two new patient code (99202) or a level-three established patient code (99213), depending on documentation of other E/M elements.

Pertinent: To reach a detailed level of history for an encounter, you need a pertinent PMFSH. According to Medicare’s Documentation Guidelines for E/M Services, you need at least one specific item from any of the three PMFSH areas to achieve the pertinent level. Pertinent PMFSH supports a detailed history level. With detailed history you’re on your way to a level-three new patient code (99203) and a level-four established patient code (99214).

Complete: A complete PMFSH includes at least one specific item from two of the three areas for the following E/M services: established patient office/outpatient services, emergency department services, established patient domiciliary care, and established patient home care. For all other E/M services, a complete PMFSH includes at least one specific item from each of the three areas. To get to level-four (99204) and five (99205) new patient visits and level-five (99215) established patient visits, you need to have a comprehensive level of history. To do that, you must find complete PMFSH in your provider’s documentation.