Wiki Past Medical History-I have seen

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mcandia

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I have seen where physicians will only document the patients current medications and expect to get credit for a PMH. I would expect that to get credit for this the documentation would have to be more significant.

Has anyone else encounted this from physicians?

Thanks - Maria
 
Pmh

Doctors are often looking for short cuts, and we as coders have to remind them that in the history taking is not where to take shortcuts. Explain the significance of the PMH to the doctor and you should see improved complaince.

Carol
 
mcandia said:
I have seen where physicians will only document the patients current medications and expect to get credit for a PMH. I would expect that to get credit for this the documentation would have to be more significant.

Has anyone else encounted this from physicians?

Thanks - Maria
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I would check with some of your carriers, I can say that in my neck of the woods, our local medicare carrier considers meds part of PMH. Not that our docs would only document that as the on PMH but it is acceptable here.
 
As part of the documentation guidelines for E/M, a patient's current medication regimen is considered part of the Past Medical History.

I would dispute any carrier or payer that tried to create a different standard. This is a widely accepted, existing industry standard.

Regardless, I do not know why you would say you "expect that to get credit for this the documentation would have to be more significant." Sometimes the medication list can be the longest part of the HPI if you have a patient on multiple meds. Also, this is perhaps the most important part of patient's PMH in terms of MDM: medication interactions are serious business. Just ask a clinician.
 
Per the E/M Documentation Guidelines, "at least one specific item" from one of the three PFSH areas, in this case Past (Medical) Hx, needs to be documented for the area to be credited.

If meds is the "one specific item" this provider documented, he rightly should receive credit for the PFSH area that meds pertains to, which per the Guidelines section of the CPT book, is the Past (Medical) History.

There will be times when you will have to request additional documentation for the provider to be credited with work performed--this is not one of them.

Seth Canterbury, CPC, ACS-EM
 
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