Podiatry Coding & Billing Alert

Hint: Check out this PFSH advice from our experts.

If you find calculating the correct level of service for your evaluation and management (E/M) services challenging, you are not alone.

Medicare’s 1995 and 1997 E/M Documentation Guidelines recognize seven components to defining E/M levels. Medicare identifies the first three elements, history, examination, and medical decision-making (HEM), as the key components.

The history component includes the following elements: chief complaint (CC); history of present illness (HPI); review of systems (ROS); and past medical, family, and social history (PFSH). The level of service determines the details you as a coder need to find in the medical documentation.  Medicare’s guidelines also explain each element of the history in further detail.

Answer the following questions to rise to the occasion and conquer PFSH challenges you may face in your podiatry coding.

Question 1: What are the different components of PFSH?

Answer 1: The 2017 CPT^® manual lists the following elements to consider when documenting a patient’s PFSH:

A. Past Medical History

Past medical history includes all of the following, according to CPT^® 2017:

• Previous major illnesses/injuries
• Prior operations
• Previous hospitalization
• Current medications
• Drug and/or food allergies
• Age-appropriate vaccine status
• Age-appropriate food/nutrition status.

Remember: CMS also includes allergies within the past history. If you are unsure of your provider’s stance on allergies, check with a rep before settling the past medical history component.

B. Family History

Family history covers an analysis of the medical events that have occurred in the patient’s family, according to CPT^® 2017. These include the following:

• The health status or cause of death for parents, siblings, and children
• Specific diseases linked to problems recognized in the CC or HPI, and/or ROS
• Family members’ diseases that may be hereditary or put the patient at risk.

“It [family history] really is a list of conditions and diseases that family members have or reasons for death,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, manager of clinical compliance with PeaceHealth in Vancouver, Washington. “However, it’s worth mentioning that it might also be reasonable to document that the patient’s family history is unknown if they are adopted or estranged from family.”

C. Social History

Social history is an age-appropriate summary of the patient’s past and current activities, according to CPT^® 2017. Examples include the following:

• Marital status and/or living situation
• Current job
• Occupational history
• Military service
• Drugs, alcohol, and tobacco use
• Education level
• Sexual history
• Other related social circumstances.

“Two of the most commonly documented elements are use of tobacco and use of alcohol,” Bucknam says. “These are almost always documented, although providers may not realize that they count as social history.”

Social history is also the correct place to include work or retirement, hobbies, school, and other factors about the patient’s life, according to Bucknam.

Question 2: What are the types of PFSH?

Answer 2: Pertinent and complete are the two kinds of PFSH.

With a pertinent PFSH, the provider reviews the history areas directly related to the problem identified in the HPI. For pertinent PFSH, the provider must document at least one item from any of the three history areas.

“A pertinent PFSH usually only addresses information specific to the condition being treated during the encounter or that might have changed since the last time care was provided,” Bucknam says. “For example, there are rarely changes infamily history and, although for some conditions family history can be very important, it does not usually have an impact on patient care.”

On the other hand, with a complete PFSH, the provider must review two or three of the history areas, depending upon the category of the E/M service.

According to the 1995 and 1997 E/M Documentation Guidelines, “A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient. A review of two of the three history areas is sufficient for other services.”

Bucknam went on to illustrate when you would see a complete PFSH.

“You would expect to see a complete PFSH for either a complete PCP [primary care physician] record annually, if the patient has a complex condition or is going to be admitted to the hospital where many different factors could influence care decisions day-to-day over time,” Bucknam says.

Question 3: How does PFSH relate to new vs. established patients?

Answer 3: There are certain situations where the nature of the care requires a comprehensive PFSH, and a new patient visit would qualify, according to Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, staff services coordinator/billing/credentialing/auditing/coding at County of Stanislaus Health Services Agency in Modesto, California.

“A new patient visit requires all facets of the PFSH to be completed to justify a comprehensive history,” Johnson says. “This is the first time that the provider is treating the patient.”

Johnson went on to explain her point further.

“Per the Medicare Fee Schedule, the reimbursement for a new office visit [99201-99205] is higher than an established service [99212-99215],” Johnson says. “This is based on the understanding that a provider should be completing a comprehensive PFSH to ensure that they have a full understanding of the patient’s history in general, and not just in relationship to that day’s visit.”

On the other hand, the PFSH for an established patient differs.

“An established patient visit would not normally require a comprehensive history as generally this was obtained when they were a new patient and the provider can use this documentation to see if there are any contributing factors,” Johnson says. “Only an update or confirmation of any changes is needed. An established visit is generally problem-focused.”