Pulmonology Coding Alert

Question: We are having trouble choosing between pertinent and complete levels of past, family and social history. Can you advise?

Codify Subscriber

Answer: A pertinent PFSH is a review of at least one of the history areas, whereas a complete PFSH is of a review of two or all three of the PFSH history areas, depending on the visit category.

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 (e.g., new patient visit). For all other E/M service levels that require a comprehensive history, you only need to document two areas (e.g., emergency department visit) (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 of the PFSH.

The distinction between pertinent and complete 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.

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.

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.