Dermatology Coding Alert

Published on Thu May 05, 2011 PDF

Per CPT®, past medical, family and/or social history is divided into three subsections.

1. Past medical history includes the patient's experience with illnesses, operations, injuries, and treatments, says Leah Gross, CPC, coding lead at a practice in St. Paul, Minn., including:

• prior major illnesses and injuries
• prior operations
• prior hospitalizations
• current medications
• allergies
• age-appropriate immunization status
• age-appropriate feeding/dietary status.

Examples: "Patient has spina bifida; patient had a kidney stone episode 12 years ago; patient is allergic to penicillin; patient had a thyroidectomy in 2009."

2. Family history includes a review of health-related events in the patient's family, including:

• health status or cause of death of parents, siblings, and children
• specific diseases related to problems identified in the chief complaint or history of the present illness, and/or system review
• diseases of family members that may be hereditary or place the patient at risk.

Examples: "Both siblings have schizophrenia; mother died at 55 of breast cancer; father has COPD."

3. Social history covers past and current activities related to:

• marital status and/or living arrangements
• current employment
• occupational history
• use of drugs, alcohol and tobacco
• level of education
• sexual history
• other relevant social factors
• activities that include sun and/or chemical exposure.

Examples: "Patient is an avid golfer; patient grew up on a farm drinking well water; patient is a smoker; patient attends daycare; patient lives in a group home."