Primary Care Coding Alert

Rule a patient’s PFSH in or out to define E/M levels.

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

Medicare’s 1995 and 1997 E/M Documentation Guidelines recognize seven components to defining E/M levels, with the first three — 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 will depend on the details you find in the documentation. The guidelines also go into specific detail about each element of the history.

With so many components to keep track of, it’s easy to feel overwhelmed. Read on to brush up on your PFSH knowledge to ensure you don’t leave money on the table.

PFSH Factors to Document (or Not)

The 2017 CPT^®  manual lists the different elements you should consider when documenting a patient’s PFSH. Your options are:

A. Past Medical History

A patient’s past medical history includes the following, according to CPT® 2017:

• Previous major illnesses/injuries,
• Prior operations,
• Previous hospitalizations,
• Current medications,
• Drug, food, and other allergies,
• Age-appropriate vaccine status, and
• Age-appropriate feeding/dietary status.

B. Family History

According to CPT^® 2017, family history encompasses an analysis of medical events that occurred in the patient’s family. These include:

• The health status or cause of death for parents, siblings, and children;
• Specific diseases linked to problems recognized in the CC, HPI, and/or ROS; and
• 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, Wash. “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

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

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

“Two of the most commonly documented elements are use of tobacco and use of alcohol,” says Bucknam. “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/retirement, hobbies, school, and other factors about the patient’s life, according to Bucknam.

I.D. 2 Types of PFSH for 2 Types of Care

There are two kinds of PFSH — pertinent and complete.

With a pertinent PFSH, the provider reviews the history areas directly related to the problem(s) 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,” says Bucknam. “For example, there are rarely changes in family 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.

“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,” according to the 1995 and 1997 E/M Documentation Guidelines.

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 [if the patient] is going to be admitted to the hospital where many different factors could influence day-to-day care decisions over time,” says Bucknam.

Know How PFSH Relates to New, Established Patients

There are certain situations where the nature of the care would require 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, Calif.

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

Johnson went on to explain further.

Per the Medicare Fee Schedule, the reimbursement for a new office visit [99201-99205] is higher than an established service [99212-99215] at the same level, says Johnson.

At upper levels, where a comprehensive history requires a complete PFSH, part of this payment differential compensates for the fact that a complete PFSH requires the provider to ask about all three elements of PFSH — to ensure that the provider “has a full understanding of the patient’s history in general, and not just in relationship to that day’s visit,” Johnson continues.

On the other hand, the complete PFSH for an established patient would differ.

An established patient visit would not normally require a complete PFSH that covers all three elements, “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,” says Johnson. “Only an update or confirmation of any changes is needed.”

Takeaway: The PFSH in an established visit is generally problem-pertinent.