Urology Coding Alert

Check your coding against these answers to see where you should focus your E/M education.Answer 1: Yes. Based on E/M guidelines, if a patient's past medical, family and social history (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 criteria.Both the 1995 and 1997 E/M documentation guidelines include the following: "A ROS and/or 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. This may occur when a physician updates his or her own [...]