Orthopedic Coding Alert

Question: When the orthopedist writes, "Past history is negative," would this satisfy the "past history" element when we decide the extent of the history portion of the E/M code? The guidelines state that "at least one specific item from any of the three history areas must be documented for a pertinent PFSH."

Colorado Subscriber

Answer: You are correct that the physician should document at least one item from one of the three areas: past medical, family, or social history. Expanding the phrase in question to "past history negative for arthritis" - or whatever the presenting problem - is appropriate.
 
Auditors may interpret "Past history negative" as meaning that the physician didn't take a history, so make sure the physician knows to document each E/M element.