Ob-Gyn Coding Alert

Make your physician's job easier by letting the patient or nurse document the history.

If your ob-gyn glosses over a patient's past, family, and social history (PFSH), you may be missing out on up to $69 per E/M.

Accurately counting the number of PFSH items could result in more money for an encounter, because the top-level E/M codes require PFSH elements in addition to an extended history of present illness, and more than 1 system reviewed. Learn these three quick tips to ensure your physician is capturing, and you're recognizing, every history component the patient mentions.

Determine the Level of PFSH

For coding purposes, the history portion of an E/M service requires all three elements -- history of present illness (HPI), review of systems (ROS), and a past, family and social history (PFSH).

Therefore, the PFSH helps determine patient history level, which has a great effect on the E/M level you can report. If you  do not know the PFSH level, you may have to select a lower level of E/M service than might otherwise be warranted..

There are three levels of PFSH: none, pertinent, and complete, says Leah Gross, CPC, coding lead at Metro Urology in St. Paul, Minn.

Pertinent: To reach a detailed level of history for the encounter (in addition to an extended HPI and the review of 2-9 systems), you need a pertinent PFSH. According to Medicare's Documentation Guidelines for E/M Services, you need at least one specific item from any of the three PFSH areas to achieve the pertinent level. When the physician asks only about one history area related to the main problem, this is a pertinent PFSH.

Complete: To reach a comprehensive level of history for the encounter (in addition to an extended HPI and the review of 10 or more systems), you need a complete PFSH which includes, per Medicare's Documentation Guidelines, at least one specific item from two of the three areas for the following categories of E/M services:

• Established patient office/outpatient services
• Emergency department services
• Established patient domiciliary care
• Established patient home care.

For all other E/M services, a complete PFSH includes at least one specific item from each of the three areas.

Pointer: You need only one element of PFSH to receive some credit for the history component of the encounter. Best bet: "Document it all. You never know what may be pertinent to the patient's current situation!" Gross advises.

Choose a Code Based on PFSH Element Requirement

Once you determine the level of PFSH your physician's documentation contains, you can see which codes that history element supports.

Beware: If your physician does not document any PFSH elements, you can only reach a problem focused or an extended problemfocused level of history, warns Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. That means the highest codes you'll be able to report are a level-two new patient code (99202) or a level-three established patient code (99213). Reporting 99202 pays $71.01 (the national unadjusted rate based on the Medicare Physician Fee Schedule assignment of 2.09 RVUs times the 2011 conversion factor of 33.9764) and 99213 pays $68.97 (2.03 RVUs).

A pertinent PFSH can support a detailed history level. With detailed history you can report a level-three new patient code (99203) and a level-four established patient code (99214). You'll earn $102.95 for 99203 (3.03 RVUs) and $102.27 (3.01 RVUs) for 99214.

To get to level-four and five new patient visits and level-five established patient visits, you need to have a comprehensive level of history, Cobuzzi says. To do that, you must find a complete PFSH in your physician's documentation. If you can achieve 99204 or 99205, you'll earn $158.33 (4.66 RVUs) and $197.06 (5.8 RVUs), respectively. You can expect $137.60 (4.05 RVUs) for 99215 -- nearly $69 more than if you're forced to report 99213 because you didn't have enough PFSH to match other supporting history elements.

Note: Since established patient office visits require two of three key components, a higher level service is still possible based on the service's examination and medical decision making (MDM) types. "For an established patient, you may decide to leave history off and count only the exam and MDM and then just have the low history," Cobuzzi says. "So, if you have a weak history, you might still reach the higher level E/M."

Count Unchanged PFSH in Current Encounter

Based on E/M guidelines, if a patient's PFSH has not changed since a prior visit your physician doesn't have to document the information again. He does, however, need to document that hereviewed the previous information to be sure it's up to date and also note in the present encounter's documentation the date and location of the initial earlier acquisition of the PFSH. Some payers will give no PFSH credit if you overlook one of these criterion.

In writing: Both the 1995 and 1997 E/M documentation guidelines include the following: A ROS and/or a PFSH obtained during an earlier encounter does not need to be rerecorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or 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.

For example: Your physician may note, "PFSH: Same as documented in my note of January 7, 2011." If there's been a change, he should record it, such as: "PFSH: Same as documented in my note of January 7, 2011, except the patient no longer drinks alcohol."

Good news: As with the review of systems (ROS), Medicare states that either the patient or nurse can fill out a history form for PFSH. "The patient usually will get a questionnaire to fill out with these questions, and often the nurse or assistant will expand on the answers." Gross says. "However, the physician must document that he or she reviewed these answers to receive credit." As long as the physician signs the form or nurse's notes and documents that he reviewed them, you can meet the requirements for PFSH with that information.