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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; [...]
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