Orthopedic Coding Alert

Reader Question:

Lean on this List for PFSH Conundrums

Question: Can you give me an example of pertinent past, family, and social history (PFSH) versus complete PFSH?

Oregon Subscriber

Answer: When it comes to PFSH, there are two kinds: pertinent and complete. Take a look at this bucket analogy from Laureen Jandroep, CPC, COC, CPC-I, CPPM, founder and CEO of Certification Coaching Organization, LLC in Oceanville, New Jersey, to better understand the differences between the two:

"Think of your P, F, and S as each being a bucket that you are trying to fill. As soon as you have one documentation item in a bucket, you are finished with the bucket. You cannot have the same documentation item in two buckets.

"If you have one bucket, then you have a pertinent PFSH. If you have two or three buckets filled, then you have a complete PFSH.

"Usually if the overall evaluation and management (E/M) sub-category requires three bullets for the history, exam, and medical decision- making, then you will need to have a complete PFSH.

"On the other hand, if the overall E/M sub-category requires two of three bullets (and ER visits), then you will only need a pertinent PFSH.

"Some sub-categories like subsequent hospital, follow-up inpatient consultations, and subsequent nursing facility care, require no PFSH."