Pediatric Coding Alert

Know your history by learning these pro tips.

You may know all the elements that go into making up a patient’s past medical, family, and social history (PFSH) properly. But how well are you documenting them?

Here are some key things to avoid the next time you review a patient’s history, along with some expert advice to help you avoid repeating history mistakes.

Don’t Confuse History Elements …

It is sometimes difficult to know where some elements fit into each of the three categories.

For example, “two commonly documented elements are use of tobacco and use of alcohol,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. Given that use of both substances have a negative effect on a patient’s health, it would be tempting to document them as medical history. However, “providers may not realize that they count as social history,” advises Bucknam.

Similarly, information about a patient’s parents or siblings can possibly be documented as family history, which calls for the “health status … of parents, siblings, and children,” or social history, which asks for details of the patient’s “living arrangements.” So, a statement such as “lives with mother and two other healthy siblings” needs to be separated into two statements such as “lives with mother and two siblings” and “both siblings are healthy,” and counted in their respective social and family categories.

… Do This Instead

Make sure any documentation templates, cheat sheets, and/or electronic medical records (EMRs) align with CPT® guidelines. Stakeholders should also be completely clear on those guidelines and the instruments and processes that your practice currently has in place to record PFSH information accurately and completely.

Don’t Document “None” for Non-Contributory Elements …

Knowing how to effectively document particular PFSH elements that are not relevant to a patient’s can be as crucial in determining the level of that patient’s care as relevant elements. This means you should never use the word “none” or “negative” for those elements that are not directly relevant to the patient’s chief complaint.

Why? “When you think about it, ‘Past Medical History — None’ doesn’t mean anything,” says Bucknam. “Of course the patient has past medical history! Allergies, immunizations, and childhood illnesses are all past medical history. The same is true of family history and social history. They must have some, so it doesn’t make sense to say ‘negative’ or ‘none,’” Bucknam adds.

But it’s also not enough to document “non-contributory.” That’s because “Medicare and many other payers interpret ‘non-contributory’ to mean ‘I don’t need to ask about this, because it would not contribute to the patient’s care. Therefore, it doesn’t count for the level of service,’” explains Bucknam.

… Do This Instead

If your pediatrician determines they are not relevant to the patient’s care, document non-contributory elements using the phrase “reviewed and non-contributory.” “This is usually interpreted to mean that it was asked, it would not affect patient care, but it will be used to support the level of care,” according to Bucknam.

Don’t Confuse Pertinent and Complete PFSH …

Understanding the difference between a pertinent and complete PFSH is important for determining the correct level of evaluation and management (E/M) services for a new patient, and can also be significant for an established patient if you’re basing one of your key components on that patient’s history.

That’s because the detailed history, which is necessary to bill 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history ...) and which could be one of the key components for 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history …), requires a pertinent PFSH, while the comprehensive history required for a 99204 or 99205, and which could be a factor in determining a 99215, requires a complete PFSH.

… Do This Instead

Make sure you understand the correct way to document either type of PFSH. Simply put, “a pertinent PFSH is a review of at least one of the history areas directly related to the problem identified in the history of present illness [HPI], whereas a complete PFSH is of a review of two or all three of the PFSH history areas,” explains Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California..

Don’t Document a Complete PFSH at Every Encounter …

Finally, you should note that your pediatrician doesn’t have to perform a complete PFSH every time he or she sees a patient. It doesn’t make sense, it’s not a good use of your provider’s time, and it’s also not necessary.

… Do This Instead

Make sure you know who can document a patient’s PFSH. Currently, “a PFSH can be recorded by a staff member, including a medical assistant, or even by the patient themselves,” Johnson notes. But “for the PFSH to be admissible for that date of service, it does need to be documented and noted as reviewed by the provider,” Johnson cautions.

Additionally, you should remember that “a complete history is usually only obtained for new patients. As an established visit is generally problem focused, a provider can use existing documentation to see if there are any contributing factors. Only an update or confirmation of any changes is needed,” Johnson adds.