Primary Care Coding Alert

Question:

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 no PFSH, you can only reach an extended problem-focused level of history, which is associated with 99202 (new patient) and 99213 (established patient).

To reach a detailed level of history, you need a pertinent PFSH, which is at least one specific item from any of the three PFSH areas, according to Medicare's Documentation Guidelines for E/M Services. A detailed history is associated with 99203 and 99214.

To go beyond that and reach a comprehensive level of history, documentation must include a complete PFSH. Per Medicare's Documentation Guidelines, a complete PFSH includes at least one specific item from two of the three PFSH areas for the following categories of E/M services: established patient office/outpatient services; emergency department services; established patient domiciliary care; and established patient home care. For all other categories of E/M services, a complete PFSH includes at least one specific item from each of the three PFSH areas.

The Medicare Documentation Guidelines also state that a PFSH 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. The review and update may be documented by describing any new PFSH information or noting there has been no change in the information and noting the date and location of the earlier PFSH.

For the above note, you may give the physician credit for a complete PFSH, which supports all office visit levels (99201-99215). The physician has documented past and social history, which is enough to substantiate a complete PFSH for an established patient. The fact that the physician also noted his review of the previously recorded PFSH is probably sufficient to also credit him with reviewing the patient's family history. The PFSH, as well as the ROS, may be recorded by ancillary staff or on a form. The physician must document that he has reviewed the form and sign and date it. Your FP has met these requirements.

For documentation that does not reference any PFSH or make any statement about it, you would not give the physician credit for PFSH. As noted, no PFSH makes the highest level of history possible an expanded problem focused history, associated with 99202 or 99213. Since established patient office visits require two of three key components, a higher level service is possible based on the service's examination and medical decision making types.