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General Surgery Coding Alert

Reader questions:

99202-99205 Take PFSH to a New Level

Published on Wed Nov 17, 2010

Question: I'm new to E/M coding, and I have a question about past, family, and social history (PFSH). We have new patients sign and date a history form, and the surgeon reviews the form. Is it OK if the surgeon's office note includes past and social history but not family history for a new patient? Answer: Your scenario about a new patient visit with documentation of two of three areas (past medical and social) qualifies as pertinent PFSH. How it works: There are three levels of PFSH: none, pertinent, and complete. With no PFSH, you can reach only a detailed history level, which is associated with 99203 (Office or other outpatient visit for the evaluation and management of a new patient ...). You may see this level for some surgical patients, but probably not for complex cases such as patients considering bariatric surgery. Pertinent: For the PFSH portion of a [...]
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