Gastroenterology Coding Alert

It may seem obvious, but PFSH is separated into three areas: past history, family history, and social history.

"Past history can be medical history, surgical history, and other personal history," says John F. Bishop, PA-C, MS, CWS, CPC.

Family history includes medical events in the patient's family line, such as hereditary diseases that put the patient at risk.

Social history reviews the individual's past and current activities. "Smoking history, alcohol history, sexual history, a whole lot of things get thrown in there," Bishop says.

When the physician asks only about one history area related to the main problem, this is a pertinent PFSH.Depending on the type of E/M you're coding, a complete PFSH may require your physician to document that he reviewed two or three of the history areas.

New patient office visits and consultations require all three areas (past, family, and social) for a complete PFSH. If you're reporting for a higher-level E/M, make sure you've covered all three history areas.

To claim a level-four or -five E/M, documentation must indicate a comprehensive history. That requires an extended HPI (document four of seven HPI); a complete ROS; and a complete PFSH.

Example: While evaluating a patient who complains of severe stomach pains, your physician makes notes about the patient's daily intake of alcohol (social), her mother's diabetes (family), and the irritable bowel syndrome she suffered in 2002 (past). This would qualify as a complete PFSH. If all other factors were in place and medical necessity were shown, the PFSH would support a comprehensive medical history.

Tabulate: Decide which history level to choose based on how you fulfilled the requirements in the chart below.

The PFSH may have direct coding implications, too. You may find yourself looking up V codes for personal and family histories of diseases.

"Often, the coders don't think of the patient's past history as having a direct effect on current issues," says Suzan Berman-Hvizdash, CPC, CEMC, CEDC, coding and compliance Manager for University of Pittsburgh Medical Center Surgery/Anesthesia. "For example, if a patient comes in complaining of abdominal pain over their appendectomy incision from 2003, the coder may not see that there is a past history element there." A diagnosis code of V15.29 (Other personal history presenting hazards to health; surgery to other organs) or V12.79 (Personal history of certain other diseases; diseases of digestive system; other) will help justify your gastroenterologist's decision to perform an EGD.

Dig in: A coder may have search for information from the physician's notes, Hvizdash says. For instance, a note may say, "Patient says he doesn't snore. However, his wife says he snores quite often."

"Here we could glean social history that the patient is married," Hvizdash says. "We actually could use this in determining medical decision making as getting historyfrom someone other than the patient."

Many payers will only accept a "family history of" code when the family member is a first-degree relative -- immediate family. "Immediate family is always the easiest degree," Hvizdash says. Immediate family includes blood siblings, mother, and father, she says.

As with the ROS, Medicare states that either the patient or nurse can fill out a history form for PFSH. As long as the physician signs the nurse's notes and documents that he reviewed them, you can meet the requirements for PFSH with information from the nurse's encounter notes.

Help your gastroenterologist: One easy way to ensure your physician documents the E/M components is to create templates they can follow.

Have your gastroenterologist reference a PFSH in the dictation, and initial and date the form. And make documenting that review a snap by including two boxes on the medical chart form for your physician to check when applicable:

• The first box should read "PFSH reviewed and unchanged as documented."

• The second box should read "All other PFSH items reviewed are unchanged as documented."

Next to each statement should be a space to reference the location and date of the original PFSH and a line for the physician's signature. If the physician wishes to indicate a review of a patient's PFSH with no changes, he can check the first box. If he makes changes, he can check the second box and document the changes separately.