Primary Care Coding Alert

Question:When a new patient is seen in our office, the patient is required to fill out a review of systems (ROS) form and history (hx) form. The hx form goes over PFSH. The patient signs and dates the form, and the physician reviews the forms and signs and dates them. The physician dictates an office note, such as patient being seen for ventral hernia. Within the physician note, he dictates past and social history but not family history. He then notes, "I personally reviewed pt's hx form dated xx/xx/201x." Although the family hx sometimes is noncontributory to the patient's illness, the FP no longer uses the statement "family hx noncontributory." Can the family history still be counted?
Answer:First, remember, the physician needs only 1 element of past medical, family, and social history to receive some credit for this history. There are three levels of PFSH: none, pertinent, and complete. With [...]