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Oncology & Hematology Coding Alert

READER QUESTIONS:

Gather Guidelines, Avoid Extra PFSH Work

Published on Mon Oct 26, 2009

Question: Is the oncologist required to document a new PFSH if it hasn't changed since the patient's last visit?

Kentucky Subscriber

Answer: E/M guidelines don't require the oncologist to document the past, family, and/or social history (PFSH) again, but he does need to document that he reviewed the previous information to be sure it's up to date.

Both the 1995 and 1997 E/M documentation guidelines include the following:

A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

• describing any new ROS and/or PFSH information or noting there has been no change in the information; and

• noting the date and location of the earlier ROS and/or PFSH.

Note that the rule applies to review of systems (ROS), as well.

Documentation example: The oncologist may note, "PFSH: Same as documented in my note of April 7, 2009." Or if there's been a change, he should record it. For example, "ROS and PFSH: Same as documented in my note of April 7, 2009, except the patient no longer uses tobacco products."

Caution: Copying the text of the previous PFSH and pasting it into the current visit documentation may be tempting, but auditors may become suspicious of identical wording. The documentation needs to show that the oncologist reviewed the information and verified its accuracy for the current visit.

Guidelines online: You can find the 1995 and 1997 documentation guidelines at www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp.

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