Part B Insider (Multispecialty) Coding Alert

For coding purposes, the history portion of an E/M service requires all three elements -- history of present illness (HPI), review of systems (ROS), and past medical, family and social history (PMFSH).  Therefore, the PMFSH helps determine patient history level, which has a great effect on the E/M level you can report.

If you do not know the PMFSH level, you will be unable to decide which level of E/M code you should use on the claim. There are three levels of PMFSH: none, pertinent, and complete.

Pertinent: To reach a detailed level of history for the encounter, you need a pertinent PMFSH. According to Medicare’s Documentation Guidelines for E/M Services, you need at least one specific item from any of the three PMFSH areas to achieve the pertinent level. When the physician asks only about one history area related to the main problem, this is a pertinent PMFSH.

Complete: A complete PMFSH includes, per Medicare’s Documentation Guidelines, at least one specific item from two of the three areas for the following categories of E/M services:

Established patient office/outpatient services

Emergency department services

Established patient domiciliary care

Established patient home care.

For all other E/M services, a complete PMFSH includes at least one specific item from each of the three areas.

Pointer: You need only one element of PMFSH to receive some credit for the history component of the encounter, but you should document it all. You never know what may be pertinent to the patient’s current situation.

Choose a Code Based on PMFSH Element Requirement

Once you determine the level of PMFSH your doctor’s documentation contains, you can see which codes that history element supports.

Beware: If your physician does not document any PMFSH elements, you can only reach an extended problem-focused level of history. That means the highest codes you’ll be able to report are a level-two new patient code (99202) or a level-three established patient code (99213). Pertinent PMFSH supports a detailed history level. With detailed history you can report a level-three new patient code (99203) and a level-four established patient code (99214). To get to level-four and five new patient visits and level-five established patient visits, you need to have a comprehensive level of history

Note: Since established patient office visits require two of three key components, a higher level service is still possible based on the service’s examination and medical decision making (MDM) types. For an established patient, you may decide to leave history off and count only the exam and MDM and then just have the low history. So if you have a weak history, you might still reach the higher level E/M."

Count Unchanged PMFSH in Current Encounter

Based on E/M guidelines, if a patient’s PMFSH has not changed since a prior visit, your doctor doesn’t have to document the information again. He does, however, need to document that he reviewed the previous information to be sure it’s up to date and also note in the present encounter’s documentation the date and location of the initial earlier acquisition of the PMFSH. Some payers will give no PMFSH credit if you overlook one of these criterion.

In writing: Both the 1995 and 1997 E/M documentation guidelines include the following: A ROS and/or a PMFSH 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 PMFSH information or noting there has been no change in the information; and

noting the date and location of the earlier ROS and/or PMFSH.

For example: Your physician may note, "PMFSH: Same as documented in my note of Dec. 1, 2012." If there’s been a change, he should record it, such as: "PMFSH: Same as documented in my note of Dec. 1, 2012, except the patient no longer drinks alcohol."