Ophthalmology and Optometry Coding Alert

Per CPT, past family and social history is divided into three subsections.

1. Past medical history includes the patient's experience with illnesses, operations, injuries, and treatments, says Leah Gross, CPC, coding lead at a practice in St. Paul, Minn., including:

• prior major illnesses and injuries
• prior operations
• prior hospitalizations
• current medications allergies
• age-appropriate immunization status
• age-appropriate feeding/dietary status.

Example: "Patient has a history of floaters, dry eye syndrome and diabetes type II."

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.

Example: "Mother has macular degeneration at age 67 and father has glaucoma."

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
• activities that include sun and/or chemical exposure.

Example: "Patient is a computer programmer spending 8-10 hours on the computer daily. Does not smoke and drinks socially."