Make your urologist's job easier by letting the patient or nurse document the history. If your urologist glosses over a patient's past medical, family, and social history (PMFSH), you may be missing out on up to $69 per E/M. Accurately counting the number of PMFSH items could result in more money for an encounter, because the top-level E/M codes require PMFSH elements. Lean these three quick tips to ensure you urologist is capturing, and you're recognizing, every history component the patient mentions. Determine the Level of PMFSH For coding purposes, the history portion of an E/M service requires all three elements -- history of present illness (HPI), review of systems (ROS), and past medical, family and social history (PMFSH). Therefore, the PMFSH helps determine patient history level, which has a great effect on the E/M level you can report. If you do not know the PMFSH level, you will be unable to decide which level of E/M code you should use on the claim. There are three levels of PMFSH: none, pertinent, and complete, says Leah Gross, CPC, coding lead at Metro Urology in St. Paul, Minn. Pertinent: Complete: Established patient office/outpatient services Emergency department services Established patient domiciliary care Established patient home care. For all other E/M services, a complete PMFSH includes at least one specific item from each of the three areas. Pointer: Choose a Code Based on PMFSH Element Requirement Once you determine the level of PMFSH your urologist's documentation contains, you can see which codes that history element supports. Beware: Pertinent PMFSH supports a detailed history level. With detailed history you can report a level-three new patient code (99203) and a level-four established patient code (99214). You'll earn $102.95 for 99203 (3.03 RVUs) and $102.27 (3.01 RVUs) for 99214. To get to level-four and five new patient visits and level-five established patient visits, you need to have a comprehensive level of history, Cobuzzi says. To do that, you must find complete PMFSH in your urologist's documentation. If you can achieve CPT 99204 or 99205, you'll earn $158.33 (4.66 RVUs) and $197.06 (5.8 RVUs), respectively. You can expect $137.60 (4.05 RVUs) for 99215 -- nearly $69 more than if you're forced to report 99213 because you didn't have enough PMFSH. Note: Count Unchanged PMFSH in Current Encounter Based on E/M guidelines, if a patient's PMFSH has not changed since a prior visit your urologist doesn't have to document the information again. He does, however, need to document that he reviewed the previous information to be sure it's up to date and also note in the present encounter's documentation the date and location of the initial earlier acquisition of the PMFSH. Some payers will give no PMFSH credit if you overlook one of these criterion. In writing: describing any new ROS and/or PFSH information or noting there has been no change in the information; and noting the date and location of the earlier ROS and/or PFSH For example: Good news: Check out page 29 for a sample intake form you can use to ensure your urologist captures a patient's full PMFSH.