Urology Coding Alert

Aspects of PFSH

Per CPT®, past medical, family and/or social history is divided into three subsections.

1. Past medical history includes the patient's experience with illnesses, operations, injuries, and treatments, says Leah Gross, CPC, coding lead at Metro Urology in St. Paul, Minn., including:

prior major illnesses and injuries

prior operations

prior hospitalizations

current medications

allergies

age-appropriate immunization status

age-appropriate feeding/dietary status.

Urology examples: "Patient had a sling operation one year ago for incontinence; patient has spina bifida; patient had a kidney stone episode 12 years ago; patient had a negative prostate biopsy six months ago," Gross says.

2. Family history includes a review of health-related events in the patient's family, including:

health status or cause of death of parents, siblings, and children

specific diseases related to problems identified in the chief complaint or history of the present illness, and/or system review

diseases of family members that may be hereditary or place the patient at risk.

Urology examples: "Mother has kidney stones; father died of prostate cancer; both siblings have vesicoureteral reflux," Gross says.

3. Social history covers past and current activities related to:

marital status and/or living arrangements

current employment

occupational history

use of drugs, alcohol and tobacco

level of education

sexual history

other relevant social factors.

Urology examples: "Patient is recently married and is a stay-at-home parent; patient is a smoker; patient attends daycare; patient lives in a group home," Gross says.

Other Articles in this issue of

Urology Coding Alert

View All