EM Coding Alert

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 Metro Urology 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 had surgery to remove his appendix one year ago; patient has spina bifida; patient had a kidney stone episode 12 years ago.

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: Mother has high cholesterol; father died of prostate cancer; both siblings have esophageal reflux.

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.

Examples: “Patient is recently married and is a stay-at-home parent; patient is a smoker; patient attends daycare; patient lives in a group home,” Gross says.