Pediatric Coding Alert

Question: A pediatrician's note indicates, "Patient complains of sore throat past two days. Temp 104. No vomiting. Cough. H1N1 exposure at school." Since seeing patients for possible H1N1, my physicians have been writing exposure comments or even documenting, "No exposure." When checking their history levels, how should I count exposure notations? Florida Subscriber Answer: Documentation, such as "Exposure at school" or "No exposure" counts as past medical family social history (PMFSH). "No exposure" goes to the patient's past experiences with illnesses, which is past medical history. "Exposure at school" gives information about the patient's current activities, which is part of social history. You need only one PMFSH item for pertinent PMFSH. Without pertinent PMFSH, the highest history that a visit can qualify for is an expanded problem focused history. "Without PMFSH, you can't have a detailed history,"supporting 99214 (Office or other outpatient visit for the evaluation and management of an [...]