Part B Insider (Multispecialty) Coding Alert
Aspects of PFSH
PDF
Per CPT®, past medical, family and/or social history is divided into three subsections. 1.
prior major illnesses and injuries
prior operations
prior hospitalizations
current medications
allergies
age-appropriate immunization status
age-appropriate feeding/dietary status.
Examples:
"Patient has spina bifida; patient had a kidney stone episode 12 years ago; patient is allergic to penicillin; patient had a thyroidectomy in 2009."2. Family history
includes a review of health-related events in the patient's family, including:health status or cause of death of parents, siblings, and children
specific diseases related to problems identified in the chief complaint or history of the present illness, and/or system review
diseases of family members that may be hereditary or place the patient at risk.
Examples:
"Both siblings have schizophrenia; mother died at 55 of breast cancer; father has COPD."3. Social history
covers past and current activities related to:marital status and/or living arrangements
current employment
occupational history
use of drugs, alcohol and tobacco
level of education
sexual history
other relevant social factors.
Examples:
"Patient is recently married and is a stay-at-home parent; patient is a smoker; patient attends daycare; patient lives in a group home."Part B Insider (Multispecialty) Coding Alert
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