Gastroenterology Coding Alert

Question: Our doctors are great about documentation, except in one area. They rarely include any information in the past, medical, family and social history (PMFSH) section other than “refer to previous visit.” This becomes a real problem when it’s the only thing standing between a lower code and a higher one. What’s the solution?

Codify Subscriber

Answer: The only solution to this situation is communication. You must explain to your physicians that the PMFSH is one of the determinants of a history level, which can impact the level of E/M service that you report. It’s very hard to calculate an accurate history level without knowing the PMFSH.

When you meet with the physicians who aren’t properly documenting the PMFSH, bring along some sample documentation showing instances where an appropriately-completed PMFSH might have increased the history level, and therefore the overall E/M level. Let them know the difference in reimbursement between the code you were forced to report and the one you could have reported so they understand the value of the PMFSH in the future.