ED Coding and Reimbursement Alert

Question: Our ED record pulls information such as this from nursing documentation:

Past Medical History (As documented by Nursing):

Angina, Hypertension, Stents, Other: elevated cholesterol; Other: emphysema on PET scan;
Other: diabetic neuropathies; Arthritis, Back pain, Fractures of lower extremities,
Fractures of upper extremities; Diabetes Type II, Other: had been on metformin-but has been taken off; Constipation; Cataract, Other: reading glasses; Lung cancer, Skin cancer, Other: right ear; Measles, Mumps, Varicella (Chicken Pox); Herpes zoster, Other: has had shingles vaccine
Past Hospitalizations and/or Surgeries: No documentation per Nursing.

Family History

Both parents deceased, Father from heart disease, Mother from cancer. Patient lives with his wife.

Social History:

Smoking (As documented by Nursing):
Smoke/use tobacco within past year: Yes, former smoker quit more than 12 months ago
Can we use this documentation to support the past medical, family, and social history requirements under the CMS documentation guidelines?

Kentucky Subscriber

Answer: The 1995 Medicare Documentation Guidelines do allow the past medical, family and social history (PFSH) to be recorded by ancillary staff if the physician or other provider also documents that they have reviewed that content and make some kind of reference to that review. The actual language looks like this:

DG: 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/her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

• 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.

DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.