Oncology & Hematology Coding Alert

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 physician reviews the form. Is it OK if the physician's office note includes past and social history but not family history for a new patient?

Maine Subscriber

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 an extended problem-focused history level, which is associated with 99202 (Office or other outpatient visit for the evaluation and management of a new patient ...). This is highly unlikely for a patient presenting with cancer.

Pertinent: For the PFSH portion of a detailed level of history, you need a pertinent PFSH, which is "a review of the history area(s) directly related to the problem(s) identified in the HPI [history of present illness]," according to Medicare's Documentation Guidelines for E/M Services (both 1995 and 1997, available at www.cms.gov/MLNEdWebGuide/25_EMDOC.asp).

A pertinent PFSH requires documentation of at least one specific item from any of the three PFSH areas, the guidelines state. CPT requires a minimum of a detailed history for 99203.

Complete: To go beyond that and reach a comprehensive level of history (required for CPT 99204 -99205), documentation must include a complete PFSH. Whether you must have documentation of two areas or three areas for a complete PFSH depends on the type of service. For a new patient office visit, you need one specific item from each of the three areas, the guidelines instruct. In contrast, you would need items from only two of the three areas for an established patient office visit.

Remember: The oncologist's first visit with a patient is likely to be a high-level E/M because of the complexity of treating cancer. If you find that a physician is consistently leaving out any of the elements in the PFSH, the compliance team may want to consider planning a session with your physicians to go over documentation requirements for E/M services.

-- Clinical and coding expertise for You Be the Coder and Reader Questions provided by Kelly C. Loya, CPC-I, CPhT,managing consultant with Sinaiko Healthcare Consulting Inc.