EM Coding Alert

Question: What would be considered an acceptable social history for a newborn? We are having some conflict with our documentation, and physicians are just saying things like "Family lives in Atlanta."

Georgia Subscriber

Answer: The social history of a patient, regardless of age, is one of the histories of Past, Family, and/or Social History (PFSH), which is then one of the three elements that define the history component of an E/M service. Both the 1995 and 1997 documentation guidelines for evaluation and management (E/M) services define social history as "an age appropriate review of past and current activities."

For newborns, the following are some examples of information you can use for social history as the parents' history can be considered:

• Occupation of mother and father
• Martial status of parents and composition of family (Other children in the home and their ages. Does the patient live with someone besides his/her parents? Does anyone else live in the home?)
• Living conditions (What kind of dwelling does the patient live in? When was the home built? Has the patient been exposed to lead paint or mold? Where is the patient's home located? What are the patient's sleeping arrangements? Does the patient attend daycare? If not, what is the childcare situation? Domestic violence in the home?)
• Household pets
• Economic circumstances
• Potential exposure to toxins like cigarette smoke 
• Do the patient's caregivers or parents use drugs or alcohol?