Pediatric Coding Alert

Question:  The pediatrician documents “PMFSH: Same as documented in my note of January 7, 2014, except the patient’s parents separated on March 1.” Can we count this documentation toward the current encounter’s level of history?

Answer:  Yes. Based on E/M guidelines, if a patient’s past medical, family and social history (PMFSH) has not changed since a prior visit, your pediatrician 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 updated and also note in the present encounter’s documentation the date and location of the initial earlier acquisition of the PMFSH. Although not consistent with CPT® guidelines, some payers will give no PMFSH credit if you overlook one of these criteria.

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."