PFSH:
How Past History Impacts Present Care and Coding
Published on Sat Jun 01, 2002
Past, family and/or social history (PFSH) is perhaps more relevant to ob/gyn than any other specialty. Patients with a personal history of sexually transmitted diseases (STDs) or miscarriage, family histories of gynecological cancer, etc., change how you approach diagnostic coding. Including the right diagnostic codes is critical to ensure that tests and procedures ordered are covered services.
History, examination and medical decision-making are the three pillars of E/M visits, and their documentation determines the level of E/M service that can be billed. But patient history is an easily overlooked portion of the patient record that cannot only drive the E/M level but also significantly impact patient care. And in the field of ob/gyn, questions about patient history are often more sensitive than in other fields, such as asking someone details about her sex life.
Patricia Horvatich, office manager for Robyn M. Cook, MD, a solo practitioner in Kealakekua, Hawaii, says that her practice uses a detailed questionnaire that asks very specific questions about patient history. "For example, rather than ask, 'What type of birth control do you use?'" Horvatich says, "we list every type of birth control, including 'withdrawal/rhythm method,' and the patient just has to circle her choice." She adds that over the years, the form has been revised for greater specificity to achieve the most accurate patient history. Aspects of PFSH Per CPT, past, family and/or social history is divided into three subsections. 1. Past history includes the patient's experience with illnesses, injuries and treatments, including:
prior major illnesses and injuries
prior operations
prior hospitalizations
current medications
allergies
age-appropriate immunization status
age-appropriate feeding/dietary status. 2. Family history includes a review of health-related events in the patient's family, including:
health status or cause of death of parents, siblings and children specific diseases related to problems identified in the chief complaint or history of the present illness, and/or system review
diseases of family members that may be hereditary or place the patient at risk. 3. Social history covers past and current activities related to:
marital status and/or living arrangements
current employment
occupational history
use of drugs, alcohol and tobacco
level of education
sexual history
other relevant social factors. For the ob/gyn patient, family or personal history of disease, and personal sexual history are likely to have the biggest impact on coding and patient management. Personal History A 38-year-old woman reports to her ob/gyn with a positive pregnancy test. This is the third pregnancy for the patient, whose first two pregnancies ended in fetal death prior to 22 weeks. Because of the risk of miscarriage, the physician schedules monthly ultrasounds to evaluate fetal development and performs several biophysical profiles during [...]
