ED Coding and Reimbursement Alert

Question:  When using either set of observation codes (99234-99236 or 99218-99220) in the ED, should I consider a complete PFSH to be when two of the three history areas are documented - or only when three of the three areas are documented? CPT states that for a "comprehensive" history, I need a chief complaint, an extended history of present illness, a review of systems directly related to the problem identified (and a review of all additional systems), and a complete past, family, and social history.

Colorado Subscriber

Answer: CPT requires a complete past, family, and social history (PFSH) for those higher-level observation codes that require a comprehensive history, such as 99220 (Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: comprehensive history, comprehensive examination, and medical decision-making of high complexity). Additionally, CMS requires one specific item from each of the three history areas of PFSH for the following code sets: office or other outpatient services for new patients, hospital observation services, hospital inpatient services (initial care), and consultations.


Unfortunately, you must have at least one element of each (past, family and social) history for all of those "initial" hospital care codes (including observation, inpatient, or the same-day admit/discharge codes).

Observation codes are among the group of evaluation and management services that require all three key components (history, exam and medical decision-making) to determine the level of service that has special consideration for PFSH in the history component.