Pediatric Coding Alert

Per CPT®, past medical, family and/or social history is divided into three subsections.1. Past medical history includes the patient's experience with illnesses, operations, injuries, and treatments, says Leah Gross, CPC, a coder in St. Paul, Minn., including:prior major illnesses and injuries prior operations prior hospitalizations current medications allergies age-appropriate immunization status age-appropriate feeding/dietary status.Pediatric examples: "Patient had otitis media one month ago, patient has spina bifida; patient had an appendicitis episode 2 years ago; patient is allergic to penicillin; patient had an tonsillectomy 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: "No others ill at home, both siblings have [...]