Pediatric Coding Alert

Make the pediatrician's job easier by letting the patient or nurse document the past, family, social history and review of systems.

If you gloss over a patient's past medical, family, and social history (PMFSH), you may be missing out on up to $69 per E/M. In this issue and future issues of Pediatric Coding Alert, we'll be showing you the basics of coding office visits using the key components of history, physical, and medical decision-making, starting with PMFSH today.

Accurately counting the number of PMFSH items could result in more money for an encounter, because the top-level E/M codes require PMFSH elements. Learn these three quick tips to ensure you are capturing, and you're recognizing, every history component the patient mentions.

Determine the Level of PMFSH

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, says Leah Gross, CPC, a coder in St. Paul, Minn.

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, which many private payers follow, 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. Best bet: "Document it all. You never know what may be pertinent to the patient's current situation!" Gross advises.

Choose a Code Based on PMFSH Element Requirement

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

Beware: If you do not document any PMFSH elements, you can only reach an extended problem-focused level of history, warns Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. That means the highest codes you'll be ableto report are a level-two new patient code (99202) or a level-three established patient code (99213). Reporting 99202 pays about $71.01 and 99213 pays $68.97, based on 2011 Medicare-equivalent payments.

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). You'll earn $102.95 for 99203 and $102.27 for 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, Cobuzzi says. To do that, you must  find complete PMFSH in the documentation. If you can achieve 99204 or 99205, you'll earn $158.33 and $197.06, respectively. You can expect $137.60 for 99215 -- nearly $69 more than if you're forced to report 99213 because you didn't have enough PMFSH.

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," Cobuzzi says. "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, the practitioners 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 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.

For example: Your pediatrician may note, "PFSH: Same as documented in my note of January 7, 2011." If there's been a change, he should record it, such as: "PMFSH:

Same as documented in my note of January 7, 2011, except the patient is no longer home schooled."

Good news: As with the review of systems (ROS), Medicare guidelines state that either the patient or nurse can fill out a history form for PMFSH. "The patient usually will get a questionnaire to fill out with these questions, and often the nurse or assistant will expand on the answers." Gross says. "However, the physician must document that he or she reviewed these answers to receive credit." As long as the physician signs the form or nurse's notes and documents that he reviewed them, you can meet the requirements for PMFSH with that information. The history of present illness (HPI), on the other hand, should be obtained and documented by the physician directly.