General Surgery Coding Alert
99202-99205 Take PFSH to a New Level
Question: I'm new to E/M coding, and I have a question about past, family, and social history (PFSH). We have new patients sign and date a history form, and the surgeon reviews the form. Is it OK if the surgeon's office note includes past and social history but not family history for a new patient?
Answer: Your scenario about a new patient visit with documentation of two of three areas (past medical and social) qualifies as pertinent PFSH.
How it works: There are three levels of PFSH: none, pertinent, and complete. With no PFSH, you can reach only a detailed history level, which is associated with 99203 (Office or other outpatient visit for the evaluation and management of a new patient ...). You may see this level for some surgical patients, but probably not for complex cases such as patients considering bariatric surgery.
Pertinent: For the PFSH portion of a detailed level of history, you need a pertinent PFSH, which is "a review of the history area(s) directly related to the problem(s) identified in the HPI [history of present illness]," according to Medicare's Documentation Guidelines for E/M Services (both 1995 and 1997, available at www.cms.gov/MLNEdWebGuide/25_EMDOC.asp).
A pertinent PFSH requires documentation of at least one specific item from any of the three PFSH areas, the guidelines state. CPT requires a minimum of a detailed history for 99203.
Complete: To go beyond that and reach a comprehensive level of history (required for 99202-99205), documentation must include a complete PFSH. Whether you must have documentation of two areas or three areas for a complete PFSH depends on the type of service. For a new patient office visit, you need one specific item from each of the three areas, the guidelines instruct. In contrast, you would need items from only two of the three areas for an established patient office visit.
Remember: If you find that a surgeon is consistently leaving out any of the elements in the PFSH, the compliance team may want to consider planning a session with your physicians to go over documentation requirements for E/M services.
General Surgery Coding Alert
- CPT 2011:
11042-11047 vs. 97597-97602: Focus on Depth to Distinguish Codes
Resolve wound care questions with this advice. Confused about when to choose a debridement code [...] - CPT 2011:
99224-99226: New Observation Codes Solve 'Middle Day' Dilemma
Use new codes with caution -- the OIG is watching. When patient observation lasts longer than [...] - Denials Management:
Bust 4 Common Myths to Overcome MUE Denial Challenges
Ignore medically unlikely edits at your peril for claim rejection. Medicare denials could mean you're [...] - You Be the Coder:
44204-44208: Count Procedure(s), Not Bowel Section(s)
Question: The surgeon laparoscopically identified a segment of the small bowel that appeared necrotic extending [...] - Reader questions:
Hernia Terminology Key to Code Selection
Question: What is the difference between umbilical hernia and ventral hernia? What do I need [...] - Reader questions:
Pick Inpatient E/M for Admission Date
Question: If our surgeon sees a patient, and later that same day, another physician admits [...] - Reader questions:
153.3 Vs. V10.05 -- Get the History Right
Question: We have a patient who had a colon resection for cancer over six months [...] - Reader questions:
10021 and 19100 Could Trip Bundle Trap
Question: If the surgeon performs both a fine needle aspiration and a core needle biopsy [...] - Reader questions:
99202-99205 Take PFSH to a New Level
Question: I'm new to E/M coding, and I have a question about past, family, and [...]
