EM Coding Alert

And know the 2019 Final Rule extends PFSH rules to CC, HPI

You know that documenting a patient’s past medical, family, and social history (PFSH) is a key component in determining E/M levels. But what do you know about the what and why of this key piece of documentation?

If you have trouble answering the question, have no fear. Follow these four tips and make errors in your history reporting a thing of the past.

Tip 1: Know What Information is Needed

First, here’s a quick PFSH refresher. When we talk about history in a coding sense, we’re actually talking about three distinct and different aspects of a patient’s life prior to encountering your provider.

Family history: According to CPT^®  guidelines, a family history is “a review of medical events in the patient’s family that includes significant information about:

• “The health status or cause of death of parents, siblings, and children;
• “Specific diseases related to problems recognized in the Chief Complaint [CC] or History of the Present Illness [HPI], and/or System Review [ROS]
• “Diseases of family members that may be hereditary or put the patient at risk.”

Past medical history: This is “a review of the patient’s past experiences with illnesses, injuries, and treatments that includes significant information about:

• “Prior major illnesses and injuries
• “Prior operations
• “Prior hospitalizations
• “Current medications
• “Allergies [eg, drug, food]
• “Age-appropriate immunization status
• Age-appropriate feeding/dietary status.”

Social history: This history is “an age appropriate review of past and current activities that includes significant information about:

• “Marital status and/or living arrangements
• “Current employment
• “Occupational history
• “Military history
• “Use of drugs, alcohol, and tobacco
• “Level of education
• “Sexual history
• “Other relevant social factors.”

Tip 2: Know the Difference Between Pertinent and Complete

CPT^® uses these two terms to distinguish between types of PFSH, but you have to turn to Centers for Medicare and Medicaid Services (CMS) guidelines to find the definitions you need to apply to both.

“A pertinent PFSH is a review of at least one of the history areas directly related to the problem identified in the HPI, whereas a complete PFSH is of a review of two or all three of the PFSH history areas,” explains Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Coding caution: You’ll need all three PFSH elements when the E/M service requires a “comprehensive assessment or reassessment of the patient,” according to CMS. For all other E/M service levels that require a comprehensive history, you only need to document two areas (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf). The E/M documentation guidelines specify which categories of E/M services require two versus three elements of PFSH to be complete.

Tip 3: Know Why This Is Important

“The distinction between pertinent and compete PFSH is important because it relates to the level of history that is supported by the documentation, which, in turn, may impact the level of E/M code supported by the documentation,” according to Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. For example, to support a level of 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity ...) for a new patient, or 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity …) for an established patient (if history is one of the three components on which you’re basing your code selection), “you will need a pertinent PFSH, which is a required element for a detailed history,” Moore reminds coders.

In order to code the highest E/M levels for new patients (99204 and 99205) and the highest level for an established patient (99215), however, you will need to document a comprehensive history. For that, you will need a complete PFSH.

Tip 4: Know Whether the 2019 MPFS Final Rule Will Change Documentation Practices

With the 2019 Final Rule, CMS instituted changes in documentation practice beginning January 1. However, this will not substantially affect the way you will record a patient’s PFSH.

Currently, “PFSH can be recorded by a staff member, including a medical assistant, or even by the patient themselves,” Johnson notes. But, “for the PFSH to be admissible for that date of service, it does need to be documented and noted as reviewed by the provider,” Johnson cautions.

This much will not change moving forward. However, “what the 2019 Final Rule does is extend those principles to recording the CC and HPI, not just the ROS and/or PFSH,” Moore notes. Additionally, “physicians will now be able focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, rather than re-record these elements, or parts thereof, if there is evidence that they reviewed and updated the previous information,” Moore concludes.