Pediatric Coding Alert

Per CPT®, past medical, family and/or 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, a coder 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.

Pediatric examples: "Patient had otitis media one month ago, patient has spina bifida; patient had an appendicitis episode 2 years ago; patient is allergic to penicillin; patient had an tonsillectomy in 2009."

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.

Examples: "No others ill at home, both siblings have cystic fibrosis; mother died at 40 of skin cancer; father has ADD."

3. Social history covers past and current activities related to:

• Parents' living arrangements
• school history
• use of drugs, alcohol and tobacco
• level of education
• other relevant social factors.

Examples: "Patient recently got a new stepfather; patient's parents are both smokers; patient attends daycare; parents just adopted a child."