Neurosurgery Coding Alert

Question: What are the two types of past medical, family, and social history (PFSH), and how do you distinguish between the two?

North Carolina Subscriber

Answer: There are two kinds of PFSH - pertinent and complete.

With a pertinent PFSH, the provider reviews the history areas directly related to the problem identified in the HPI. For pertinent PFSH, the provider must document at least one item from any of the three history areas.

"A pertinent PFSH usually only addresses information specific to the condition being treated during the encounter or that might have changed since the last time care was provided," says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC,  revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. "For example, there are rarely changes in family history and, although for some conditions family history can be very important, it does not usually have an impact on patient care."

On the other hand, with a complete PFSH, the provider must review two or three of the history areas, depending upon the category of the evaluation and management (E/M) service.

"A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient," according to the 1995 and 1997 E/M Documentation Guidelines. "A review of two of the three history areas is sufficient for other services."

Bucknam went on to illustrate when you would see a complete PFSH.

"You would expect to see a complete PFSH for either a complete PCP [primary care physician] record annually, if the patient has a complex condition or is going to be admitted to the hospital where many different factors could influence care decisions day-to-day over time," Bucknam says.