Primary Care Coding Alert

And know if documentation will change in 2019.

If you code evaluation and management (E/M) services, you know how important it is to document a patient’s past medical, family, and social history (PFSH) properly.

Get it wrong, and not only do you risk coding E/M levels incorrectly, but you also risk compliance problems down the road.

Follow these four tips, however, and errors in your history reporting will be a thing of the past.

Tip 1: Know What Information is Needed

First, here’s a quick PFSH refresher. When we talk about history in a coding sense, we’re actually talking about three distinct and different aspects of a patient’s life prior to encountering your provider.

Family history: According to CPT^® guidelines, a family history is “a review of medical events in the patient’s family that includes significant information about:

• “The health status or cause of death of parents, siblings, and children;
• “Specific diseases related to problems recognized in the Chief Complaint [CC] or History of the Present Illness [HPI], and/or System Review [ROS]
• “Diseases of family members that may be hereditary or put the patient at risk.”

Past medical history: This is “a review of the patient’s past experiences with illnesses, injuries, and treatments that includes significant information about:

• “Prior major illnesses and injuries
• “Prior operations
• “Prior hospitalizations
• “Current medications
• “Allergies [eg, drug, food]
• “Age-appropriate immunization status
• Age-appropriate feeding/dietary status.”

Social history: This history is “an age appropriate review of past and current activities that includes significant information about:

• “Marital status and/or living arrangements
• “Current employment
• “Occupational history
• “Military history
• “Use of drugs, alcohol, and tobacco
• “Level of education
• “Sexual history
• “Other relevant social factors.”

Tip 2: Know the Difference Between Pertinent and Complete

CPT^® uses these two terms to distinguish between types of PFSH, but you have to turn to Centers for Medicare and Medicaid Services (CMS) guidelines to find the definitions you need to apply to both.

“A pertinent PFSH is a review of at least one of the history areas directly related to the problem identified in the HPI, whereas a complete PFSH is of a review of two or all three of the PFSH history areas,” explains Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Coding caution: You’ll need all three PFSH elements when the E/M service requires a “comprehensive assessment or reassessment of the patient,” according to CMS. For all other E/M service levels that require a comprehensive history, you only need to document two areas (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf). The E/M documentation guidelines specify which categories of E/M services require two versus three elements of PFSH to be complete.

Tip 3: Know Why This Is Important

“The distinction between pertinent and compete PFSH is important because it relates to the level of history that is supported by the documentation, which, in turn, may impact the level of E/M code supported by the documentation,” according to Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. For example, to support a level of 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity ...) for a new patient, or 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity …) for an established patient (if history is one of the three components on which you’re basing your code selection), “you will need a pertinent PFSH, which is a required element for a detailed history,” Moore reminds coders.

In order to code the highest E/M levels for new patients (99204 and 99205) and the highest level for an established patient (99215), however, you will need to document a comprehensive history. For that, you will need a complete PFSH.

Tip 4: Know Whether the 2019 MPFS Final Rule Will Change Documentation Practices

As we reported in Primary Care Coding Alert v20n12, CMS instituted changes in documentation practice beginning January 1, 2019. However, this will not substantially affect the way you will record a patient’s PFSH.

Currently, “PFSH can be recorded by a staff member, including a medical assistant, or even by the patient themselves,” Johnson notes. But, “for the PFSH to be admissible for that date of service, it does need to be documented and noted as reviewed by the provider,” Johnson cautions.

This much will not change moving forward. However, “what the 2019 Medicare Physician Fee Schedule final rule does is extend those principles to other parts of E/M documentation,” Moore notes.

“For instance, the final rule will allow ancillary staff to record the CC and HPI, not just the ROS and/or PFSH. Likewise, for both history and exam, not just ROS and/or PFSH, the final rule will allow physicians to focus their documentation on what has changed since the last visit or on pertinent items that have not changed rather than re-documenting a defined list of required elements.” Moore points out.

In other words, “physicians do not need to re-record these elements, or parts thereof, if there is evidence that they reviewed and updated the previous information,” Moore concludes.