Pediatric Coding Alert

Question: A grandmother brings her granddaughter in for a swollen and sore wrist. The woman relates that the child has been complaining of the symptoms for the past week. The pediatrician documents "no history of trauma." But he also notes that the patient was in a motor-vehicle accident last month, which he believes is unrelated to the injury. Should the pediatrician consider the history documentation part of the physician's review of systems (ROS) or past, family, social history (PFSH)?

Massachusetts Subscriber Answer: Per CPT, the ROS is "an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced." The documentation of the motor-vehicle accident doesn't fit this definition and is more consistent with CPT conception's of past history, which is a review of the patient's past experiences with illnesses, injuries and treatments. Therefore, the pediatrician could consider the comment part of PFSH or not at all.
 
- Answers to You be the Coder and Reader Questions provided by Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.; Barbara J. Cobuzzi, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a premier medical billing company in Lakewood, N.J.; Kent Moore, a healthcare financing and delivery systems manager in Leawood, Kan.; and Julia M. Pillsbury, DO, FACOP, FAAP, a pediatrician at the Center for Pediatric Medicine in Dover, Del.