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mizzmaryb

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I see a lot of questions regarding History component of EM leveling. Mostly pertaining to HPI and ROS but what about a question regarding the PFSH?

Am I understanding this correctly, if the dr does list past med, family, and social history(ies) that are MED NECESSARY to the present illness/reason pt is being seen then this could either be epf, detailed, or comp? So, if it's not MED NECESSARY then it wouldn't be counted even though it's documented? such as this example:
CC:
1. HAND LACERATION Pt was opening a can and cut left hand..
HPI:
General:
This 78-year-old female presents for evaluation of a laceration to her left hand sustained this evening while opening a can of soup. The metal lid bent backwards cutting her left hand. As we would not stop bleeding she came to the urgent care for evaluation. Denies any other injuries sustained. States she has not had a tetanus in over 10 years.

Medical History: Overactive bladder, Left breast cancer -- s/p lumpectomy and radiation.

Family History: 4 brother(s) , 1 sister(s) - healthy. 1 son(s) , 4 daughter(s) - healthy.

Social History: no Alcohol. Smoking: Current smoker? No, date asked 11/10/2010.

Medications: Arimidex Tablet 1 MG 1 tablet Once a day, Levoxyl Tablet 112 MCG 1 tablet every morning on an empty stomach Once a day, Detrol LA Capsule Extended Release 24 Hour 4 MG 1 capsule Once a day, Doxycycline #14 Tablet 100mg 1 tablet twice a day, stop date 11/17/2010, Valacyclovir HCl Tablet 1000 mg 2 tablets Atonset cold sores and repeat once only after 12 hours, Benazepril HCl

Allergies: N.K.D.A.

Would the medical history of "overactive bladder, left breast cancer count if the medications weren't listed? and what about the fam hx and social? would these be counted as "history area(s) directly related to the problem(s) in the HPI?

Please help me understand this. thanks!
 
I'm a bit confused when you talk about "medically necessary" in this regard. The MD cannot determine what is pertinent to the current problem until he/she asks the questions.

If the history elements are listed and have been reviewed, asked, documented, etc. then they should count toward the billed level of service.

Pertinent positives and negatives MUST be documented when it comes to the Review of Systems.

As you state, the "overactive bladder" may not have anything to do with the current problem. However, the MD had to ask about issues the patient was having in order to determine, bleeding disorders, seizures perhaps, etc. The fact that he got "overactive bladder" doesn't negate his need for the knowledge. He is documenting everything he learned about the patient to make an appropriate decision for this patient now. But, also so that when the patient returns, he will have all the information.
 
sorry, i mean medically necessary as in history area(s) directly related to the problem. even though it's documented is it still counted towards the PFSH. it looks like you answered my question though. it still does count towards the level because md reviewed this info. i guess i'm confusing it with the examination, where the exam of body areas/organ systems need to be related to the condition.

i got this off of UW physicians Medicine-Compliance website:
"PFSH- The level of service is based on the provider’s review and documentation of the medically appropriate historical information. If (per the documenter) an element of history is not relevant to the patient’s condition, it may not be counted toward the level of history obtained during the visit."

Another question, if in our chart note the past med hx is listed as such, does it still count?
"Past Medical History
heart disease No
atrial fibrillation No
hypertension No
diabetes No
high cholesterol No
cancer No
asthma No
thyroid disease No
kidney disease No
ulcers No"
 
That's a great past history. If the form they are reviewing (or the EMR they are entering into) has yes/no questions, this shows that it was read by the patient or reviewed by the provider.

Hope that helps!
Suzan
 
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