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Gastroenterology Coding Alert

Master Past, Family, Social Hx to Knock Out E/M, Dx Coding

Published on Sat Apr 04, 2009

Good notes point you to codes that support services. When your physician performs an E/M service, he takes a past family and social history as part of the patient's medical history. For coding purposes, the history requires all three elements -- history of present illness (HPI), review of systems (ROS), and past family and social history (PFSH) -- be met, so failing to conduct and document any of these areas will lessen the history level. Therefore, the PFSH helps determine patient history level, which has a great effect on the E/M level. If you do not know the PFSH level, you will be unable to decide which level of E/M code you should use on the claim. Know Your PFSH Basics It may seem obvious, but PFSH is separated into three areas: past history, family history, and social history. "Past history can be medical history, surgical history, and other personal history," says [...]
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