ED Coding and Reimbursement Alert

Payers reward practices that record robust personal,family, and social history (PFSH) when the provider addresses them out of medical necessity.

Bottom line: Accurately counting the number of PFSH items could result in an extra $50 or more for the encounter, as the top-level ED E/Ms require PFSH elements. Check out these quick tips on fishing PFSH items out of encounter notes.

PFSH recording is not always a required part of the history portion of an ED E/M service (99281-99285); in fact, you can report up to 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) without any PFSH info on the claim, says Pam Cline, RHIT, senior coding supervisor for Medical Account Services in Frederick, Md. Code 99283 pays about $61 (1.70 transitioned facility relative value units [RVUs] multiplied by the 2009 Medicare  conversion rate of 36.0666.)

To code a level-four or -five ED E/M, however, you will need to include the following PFSH proof:

• Pertinent: A pertinent PFSH addresses at least one of the three PFSH items. This level might support up to 99284 (... a detailed history; a detailed examination; and medical decision making of moderate complexity ...), which pays approximately $114 (3.17 RVUs).

• Complete: A complete PFSH addresses two or three of the PFSH elements. This level might support up to 99285 (... within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...), which pays approximately $170 (4.72 RVUs).

Collecting PSFH helps the provider with diagnosis coding and supports the level of service chosen, Cline explains. So be aware of potential PFSH items on each ED E/M claim.

Since the ED is a setting where all patients are new, the provider often needs PFSH facts. "The provider may need to have certain questions answered in order to know what direction the care plan should follow," according to Cline.

When considering elements of past history, look for information on the patient's allergies, current medications, past illnesses and surgeries, and any conditions that may be relevant to the presenting problem, Cline explains.

Example: A patient is taking insulin to treat her diabetes. The physician notes this, in case he decides to prescribe medication that may interact negatively with insulin.

Family history is "a review of medical events in the patient's family, including diseases that may be hereditary or place the patient at risk, explains Beth Greenfield, RHIT, who works in the outpatient coding  department at Oneida Health Care Center in New York.

Family history also includes any inheritable condition or disease that is relevant to why the patient is seeking medical attention.

Example: A patient presents with rectal bleeding. The physician notes that the patient's family has a history of colon cancer, as this will affect treatment.

Be careful not to treat social history as an afterthought; many times, coders will miss a social history item and an opportunity to tag a pertinent PFSH on an E/M. "Social history is just as important" as family and past history, Cline reminds.

Items you should consider when searching for social history include:

• workplace

• living conditions

• marital status

• age-appropriate review of past and current activities.

When considering review of activities, Greenfield says you might include the following issues: domestic violence; impairment; language; living situation; diet; use of social services; special needs, if any; use of drugs, alcohol, or tobacco; and sexual history. (Note: This is not a complete list of possible social history elements.)

Example: A patient is rushed to the ED after a suicide attempt. The physician writes "Px uses heroin daily" in the notes, as this is an important factor in treatment.

Consider this example from Cline, in which the physician performs a complete PFSH (Try to pick out all three elements): A 50-year-old man presents to the ED with chest pain.

He has been experiencing shortness of breath and upper extremity discomfort for the past four hours. The patient has a history of coronary artery disease (CAD) and hypertension (HTN). He is and has been a smoker for 20 years, and his father had cardiovascular disease and died of an acute myocardial infarction (MI) at age 53.

In this instance, the physician addressed past (CAD, HTN), family (father's CAD), and social (smoker) histories.